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Dn«^  ^„HX64069125 

RD81  T84  1 896         Artificial  anaesthes 


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ARTIFICIAL    ANiESTHESIA. 


A  MANUAL 


OF 


ANESTHETIC  AGENTS 


AND  THEIR 


EMPLOYMENT  IN  THE  TEEATMENT  OF  DISEASE. 


BY 

LAURENCE  TURNBULL,  M.D.,  Ph.G., 

AURAL  Surgeon  to  the  Jefferson  Medical  College  Hospital,  Phila- 
delphia ;  Late  Honorary  President  to  the  Otological  Subsec- 
tion OF  THE  British  Medical  Association,  and  of  the 
Section  of  Laryngology  and  Otology  of  the 
American  Medical  Association. 


FOURTE  EDITION.    REVISED  AND  ENLARGED. 


WITH   ILLUSTRATIONS. 


PHILADELPHIA  : 

P.  BLAKISTON^,  SO^  &  CO., 

No.  1012  Walnut  Street. 
1896. 


Entered  according  to  Act  of  Congress,  in  the  year  1896,  by 

LAURENCE  TURNBULL,  M.D., 

In  the  office  of  the  Librarian  of  Congress.    All  rights  reserved. 


In  1847  the  late  Dr.  Oliver  Wendell  Holmes  created  the  words 
artificial  ausesthesia,  and  wrote:  "Nature  herself  is  working  out  the 
primal  curse  which  doomed  the  tenderest  of  her  creatures  to  the 
sharpest  of  her  trials ;  but  the  fierce  extremity  of  suffering  has  been 
steeped  in  the  waters  of  forgetfulness,  and  the  deepest  furrow  in  the 
knotted  brow  of  agony  has  been  smoothed  forever." 


"  If  America  had  contributed  nothing  more  to  the  stock  of  human 
happiness  than  anaesthetics,  the  world  would  owe  her  an  everlasting 
debt  of  gratitude." — The  late  Professor  Samuel  D.  Gross. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/artificialanstOOturn 


PREFACE  TO  THE  FOURTH  EDITION. 


Haying  been  informed  by  m.v  publishers  that  it  would  be 
necessary  to  issue  a  Fourth  edition  of  my  "  Manual  of  Anaes- 
thetics "  this  j-ear  (1896),  it  has  been  my  endeavor  to  bring  the 
Tvhole  subject  of  artificial  anaesthesia  and  anaesthetics  up  to  the 
present  time,  being  careful  to  obtain  all  the  most  notable  dis- 
coveries of  the  last  six  years. 

I  have  examined  all  the  important  works  published  during 
the  interval,  testing  in  almost  every  instance  the  new  anaes- 
thetics, or  modifications  of  the  old,  on  mj^self  or  my  friends, 
also  the  mechanical  contrivances  for  their  administration. 

In  visiting  Europe  in  1892-3,  met  and  acted  with  the  Com- 
mittee on  Anaesthetics  of  the  British  Medical  Association  at 
the  meetings  at  Nottingham  and  London — at  the  former  pre- 
sented a  paper  of  statistics  on  the  subject  of  anaesthetics.  By 
special  invitation — visited  the  Universities  of  Edinburgh  and 
Glasgow  to  witness  the  Scotch  method  of  administering  chloro- 
form, a  careful  and  conscientious  statement  of  which  I  have 
endeavored  to  give. 

It  is  somewhat  remarkable  that  the  fourth  edition  of  this 
book  should  be  issued  on  the  fiftieth  anniversary  of  the  dis- 
covery and  introduction  of  ether  (October  6,  1846). 

It  is  the  one  sj'stemic  anaesthetic  which  has  proved,  during 
all  these  years,  the  most  available  and  the  most  free  from 
danger. 

Numerous  valuable  anaesthetics  have  been  brought  to  the 
knowledge  of  the  profession,  but  all  had  to  gi\e  place  to  ether. 
A  careful  study  of  its  constituents  and  its  mode  of  preparation, 
with  a  careful  trial  of  its  physiological  efi'ects,  have  proved  its 
value.  Above  all,  its  use  in  two  hospitals  with  which  we  have 
been  connected  for  a  long  time  has  never  resulted  in  a  death, 


VI  PREFACE    TO    THE    FOURTH    EDITION. 

either  in  our  own  practice  or  in  those  operations  in  which  we 
have  assisted.  Careless  and  inconsiderate  individuals  now 
and  then  bring  discredit  upon  it,  but  in  the  majority  of  cases 
they  should  be  blamed — and  not  the  anaesthetic.  No  one 
should  be  allowed  to  administer  any  angesthetic  without  a  cer- 
tain amount  of  tuition,  and  no  one  should  receive  a  diploma 
until  he  has  shown  a  knowledge  of  the  chemical  composition^ 
and  physiological  action  of  such  anaesthetics. 

Efforts  have  been  made  to  bring  discredit  upon  ether.  The 
investigations  and  experiments  of  Drs.  J.  Chalmers  DaCosta, 
H.  C.  Wood  and  Carter  have  endeavored  to  prove  that  ether 
contains  dangerous  elements  in  the  changes  which  it  undergoes 
in  the  system.  Also  in  the  secondary  changes  which  result  in 
its  after-effects,  but  these  experiments  require  confirmation 
before  being  received  by  the  profession.  The  action  of  chloro- 
form upon  the  heart,  kidneys  and  liver,  and  the  deleterious 
changes  resulting  from  its  use,  have  been  confirmed  by  numer- 
ous observers  and  experimenters,  both  at  home  and  abroad. 
We  have  given  as  complete  as  possible  a  series  of  tables  of 
death  from  both  ether  and  chloroform,  obtained  with  much 
labor  and  trouble  from  all  the  reliable  sources  within  reach, 
only  regretting  that  they  are  not  so  perfect  as  could  be  desired. 

These  tables  fully  confirm  our  original  views,  founded  upon 
personal  observation,  viz.,  that  ether  is  the  safest  systemic 
anaesthetic  to  be  employed,  and  they  further  confirm  the  state- 
ments published  upon  the  subject  in  the  first  edition  of  this 
work. 

I  desire  to  acknowledge  many  courtesies  at  the  hands  of 
members  of  the  medical,  pharmaceutical,  and  dental  professions. 

255  South  Seventeenth  Street,  Philadelphia, 
October,  1896. 


PEEFACE  TO  THE  THIRD  EDITION. 


The  Author  has  endeavored,  in  this  the  Third  Edition  of 
his  Manual,  to  make  a  thorough  revision  of  the  whole  subject 
of  Artificial  Anaesthesia.  The  time,  he  thinks,  has  arrived, 
after  forty-five  j^ears'  (1844-1889)  trials,  of  these  most  wonder- 
ful and  beneficent  agents,  by  the  medical  and  surgical  profes- 
sion, to  have  some  definite  and  positive  opinion,  as  to  their 
relative  safety  in  the  various  operations,  and  the  risks  and  re- 
sponsibility attending  their  use,  in  the  healthy  and  diseased 
conditions  of  the  human  body. 

By  a  careful  and  conscientious  study  of  each  agent,  its  natu- 
ral and  physiological  characteristics,  and  peculiarities,  each  and 
every  medical  man  can,  and  should,  select  the  one  which  he 
knows  and  feels  will  be  just  suitable  in  the  peculiar  case  on 
hand. 

By  the  discovery  of  true  and  positive  local  angesthetics,  and 
by  their  careful  use  in  all  minor  operations  in  surgery,  much 
of  the  risk  to  life  is  prevented. 

All  hopes  have  passed  away — for  the  time  being  at  least — 
that  any  one  of  the  systemic  ansesthetics  is  absolutely  free 
from  risk  to  life,  for  we  now  know,  full  well,  that  angesthesia 
carried  to  the  efi'ect  of  a  profound  impression  on  the  human 
subject,  sufficient  for  a  capital  operation,  is  but  a  step  from 
death. 

It  has  been  proven  in  numerous  cases  that  it  requires  but  a 
slight  excess  in  the  quantity  employed,  perhaps  a  lack  of 
atmospheric  air,  great  fear  or  dread  concerning  operation  or 
anaesthetic,  the  faulty  or  non-action  of  a  deranged  kidney  or 
heart,  perchance  a  careless  administration,  and  the  patient  is 
dead.  In  making  the  additions  and  alterations  to  our  Manual, 
necessary  at  the  present  day,  many  changes  have  led  to  an 
increase  in  the  size  of  this  book. 

We  would  advise  all  who  are  obliged  to  use  anaesthetics  to 
memorize  the  prominent  points,  so  that  when  a  case  of  emer- 


Vlll  PREFACE    TO    THE    THIRD    EDITION. 

gency  arises  it  will  not  be  necessary  to  seek  information  in  the 
book,  and  all  necessary  haste,  worry  and  confusion  would  be 
avoided,  knowing  just  what  to  do  for  the  best  interest  of  the 
suffering  patient,  nigh  unto  death. 

The  indiscriminate  and  careless  administration  of  the  most 
powerful  anaesthetic  agents  is  the  crying  evil  of  the  present 
day,  and  we  feel  sure  that  in  the  near  future  legislative  action 
will  be  taken  to  prevent,  under  heavy  penalty,  any  one  from 
giving  an  anaesthetic,  unless  he  or  she  be  provided  with  a  cer- 
tificate that  they  fully  understand  the  chemical,  physiological 
and  medical  agents  they  are  about  to  employ,  and  have  had 
experience  in  their  use,  under  a  competent  surgeon,  and  have 
been  subjected  to  a  careful  examination  of  the  knowledge  they 
have  thus  acquired. 

Human  life  is  too  valuable  to  be  destroyed  by  incompetent 
administrators  of  such  beneficent  yet  death-giving  agents. 

The  following  is  the  most  recent  warning  on  this  subject: 
"The  announcement  that  the  anaesthetist  in  a  fatal  case  of 
chloroform  narcosis,  at  Sydney,  Australia,  has  been  found 
guilty  and  sentenced  to  pay  two  hundred  pounds  damages,  on 
the  ground  that  the  anaesthetic  had  been  improperly  adminis- 
tered, comes  with  rather  a  startling  effect.  While  no  conscien- 
tious man,  be  he  lay  or  medical,  will  dispute  the  justice  of  such 
a  verdict,  when  negligence  is  clearly  proven,  difficulties  arise 
when  such  matters  are  adjudicated  by  a  jury  of  persons,  who, 
whatever  their  intelligence,  are  profoundlj^  ignorant  of  what 
constitutes  negligence  in  this  respect. 

"It  would  be  but  a  step  further  for  juries  to  enforce  the 
opinion,  which  has  been  gaining  ground,  as  to  the  advisability 
of  giving  chloroform  at  all,  unless  specially  indicated.  Still, 
this  is  a  matter  well  within  the  discretion  of  the  medical  man, 
and  it  would  be  impolitic,  as  well  as  unjust,  to  fetter  the  exer- 
cise of  that  discretion  by  a  fear  of  legal  consequences. 

"  Short  of  negligence,  amounting  to  a  criminal  act,  we  cannot 
conceive  of  such  a  verdict  in  this  country  (England),  and  we 
sincerely  hope  that  the  example  will  not  be  the  means  of  im- 
posing an  additional  horror  to  the  life  of  medical  men,  who 
have  enough  to  attend  to  in  guarding  themselves  against  vexa- 


PREFACE    TO    THE    THIRD    EDITION.  IX 

tious  actions  for  having  signed  lunacy  certificates,  and  in  avoid- 
ing the  wiles  of  designing  women  with  an  eye  to  blackmail."* 

The  subject  of  the  administrations  of  ether  per  rectum  still 
claims  some  interest.  The  author  retains  part  of  the  literature 
on  that  subject,  modifying  and  giving  the  most  recent  cases 
which  have  been  reported.  The  application  of  such  powerful 
agents  by  the  rectum  offers  many  objections  to  general  use, 
although  in  some  rare  cases  it  can  be  resorted  to  with  success 
when  cocaine  is  neither  admissible  nor  sufficiently  powerful. 

In  this  edition  of  the  work  the  author  has  retained  the 
description  and  illustrations  of  the  various  inhalers.  Some  are 
not  recommended  as  highly  as  others,  but  all  have  certain 
merits  and  demerits ;  still,  this  department  has  been  found  of 
practical  use  in  the  saving  of  time  to  those  who  are  not  famil- 
iar with  the  various  modifications  made  or  work  performed. 
The  author  desires  to  return  thanks  to  Dr.  Buxton  for  his  kind- 
ness in  allowing  his  publishers  to  furnish  several  illustrations  of 
instruments  and  one  of  tracings,  the  former  being  in  constant 
use  and  highly  thought  of  by  the  physicians,  surgeons  and 
dentists  of  Great  Britain,  Here,  also,  he  makes  a  general 
acknowledgment  of  having  freely  availed  himself  of  Dr.  Bux- 
ton's labor  in  original  communications  sent  to  him,  knowing 
how  much  they  will  be  appreciated  by  his  professional  brethren 
in  this  country,  he  "being  administrator  of  anaesthetics  in 
several  London  hospitals." 

The  author  desires  to  acknowledge  many  courtesies  at  the 
hands  of  several  members  of  the  medical  profession. 

He  is  also  indebted  to  the  liberality  of  the  S.  S.  White  Den- 
tal Manufacturing  Co.,  of  this  city,  for  the  use  of  valuable  cuts 
of  instruments  and  apparatus.  Also  to  Parke,  Davis  &  Co., 
Detroit,  Mich. 

The  author's  sole  object  has  been  to  make  this  work  a  scien- 
tific yet  practical  and  safe  guide,  no  labor  nor  expense  having 
been  spared  in  attempting  to  accomplish  this  object. 

*  Dr.  E.  Hart,  British  Medical  Journal . 

1502  Wal>"UT  Street,  Philadelphia, 
December,  1889. 


PREFACE  TO  THE  SECOND  EDITION. 


The  rapid  sale  of  a  large  edition  of  this  work  in  the  short 
period  of  one  j^ear,  shows  the  appreciation  with  which  it  has 
been  received  by  the  medical  and  dental  press  and  professions. 
Its  success  has  induced  the  author  to  revise  the  subject-matter 
and  rewrite  several  of  the  articles.  To  make  the  volume  more 
worthy  of  the  favor  of  the  profession,  a  number  of  new  and 
original  experiments  have  been  made,  especially  with  hydro- 
bromic  ether.  The  boiling  points  and  relative  time  of  evapo- 
ration of  the  several  agents  employed  in  mixed  anaesthetics, 
and  the  best  proportion  in  which  ether,  alcohol  and  chloroform 
should  be  united  have  been  determined  ;  also  a  continuation  of 
the  experiments  on  the  action  of  anaesthetics  on  the  blood,"  the 
use  of  the  spectroscope  in  relation  to  anaesthetics,  more  espe- 
cially nitrous  oxide. 

In  this  second  edition  there  will  be  found  many  more  prac- 
tical suggestions  as  to  the  employment  of  anesthetics  that  are 
safe,  and  the  rules  for  their  adoption  or  reasons  for  the  rejection 
of  some  of  them  in  different  cases,  grouped,  and  made  conve- 
nient, so  that  the  student  can  memorize  them,  and  be  fully 
prepared  for  any  emergency.  As  has  been  well  observed  in  a 
review  of  this  work  by  the  distinguished  editor  of  the  Dental 
Cosmos,  "When  trouble  comes  to  a  patient  from  any  cause 
during  the  anaesthetic  state,  it  is  not  a  good  time  to  hunt  up 
information." 

The  new  table  of  deaths  from  chloroform  which  has  been 
added,  and  in  the  preparation  of  which  much  time  and  labor 
have  been  expended,  will  be  found  of  special  interest  and  vital 
importance  in  regard  J;o  the  sex,  age,  character  of  operation^ 
time  at  which  the  patient  died,  quantity  of  chloroform  used, 
and  form  of  apparatus  employed,  general  condition  of  patient^ 


PREFACE    TO    THE    SECOND    EDITION.  XI 

prominent  symptoms  of  chloroform-poisoning,  causes  of  death 
and  post-mortem  appearances.  A  new  ether  inhaler  has  been 
described  and  illustrated,  which  has  been,  and  is  now,  emploj'ed 
in  the  clinical  service  of  Jefferson  College  Hospital. 

A  bibliograph}"  published  in  the  first  edition  has  been  omitted, 
but  additional  old  or  new  works  which  were  not  then  intro- 
duced, or  cannot  be  found  mentioned  in  the  body  of  this  work, 
have  been  printed  for  reference. 

A  historical  sketch  of  the  discovery  of  anEesthesia  at  the  end 
of  the  previous  edition  has  also  been  omitted,  as  more  space 
has  been  devoted  to  the  subject  in  our  introduction,  but  full 
references  to  all  authorities  on  the  subject  have  been  given. 

There  has  been  introduced  a  notice  of  the  metric  system  in 
accordance  with  the  recommendations  of  the  ''American  Med- 
ical Association  "  at  its  last  meeting,  at  Atlanta,  in  May,  1879  ; 
also  a  table  of  the  Centigrade  and  Fahrenheit  thermometric 
scales.  More  space  has  likewise  been  assigned  to  the  phj^sio- 
logical  and  therapeutic  action  of  anaesthetics  in  disease.  In 
most  of  the  instances  where  a  remedy  has  been  recommended, 
the  authority  has  been  quoted,  or  we  have  tested  its  therapeutic 
value  in  an  extensive  private  practice,  or  in  the  daily  clinics  of 
two  large  public  institutions. 

It  was  found  impossible  to  acknowledge,  in  every  instance,, 
the  source  from  which  all  contained  facts  have  been  obtained, 
but  in  the  majority  of  instances  we  have  endeavored  to  give 
credit  to  every  original  worker  in  the  field  of  progress.  The 
author  desires  to  acknowledge  many  courtesies  at  the  hands  of 
several  eminent  members  of  the  profession  ;  but  he  is  espe- 
cially indebted  to  his  son.  Dr.  Charles  S.  Turnbull,  and  others. 

1502  Walnut  Steeet,  Philadelphia, 
June,  1879. 


PEEFACE  TO  THE  FIRST  EDITION. 


This  little  work  was  originally  written  by  the  Author  as  a 
report  for  a  medical  society,  and  was  subsequently  extended  to 
its  present  form  to  supply  a  want  that  evidently  exists  at  the 
present  day,  for  a  convenient  hand-book  on  the  administration 
of  the  various  anaesthetics,  that  the  practitioner  of  medicine  or 
dentistry  can  consult,  to  enable  him  to  decide  which  one  he  can 
best  employ.  Many  valuable  books  have,  unquestionably,  been 
written  on  the  subject  of  anaesthetics,  but  as  far  as  the  writer's 
observations  extend,  none  of  a  practical  character  have  appeared 
within  the  last  few  years.  Much  useful  matter  in  relation  to 
sulphuric  ether,  "  nitrous  oxide,"  and  chloroform,  emploj^ed  as 
anaesthetics,  has  accumulated  within  this  period,  but  this  valu- 
able information  is  contained  in  various  monographs,  journals, 
otc,  where,  associated  with  what  is  extraneous,  it  is  unprofit- 
able to  the  busy  practitioner. 

The  object  of  this  work  may  be  stated  to  be  : 

First.  To  give  in  as  concise  a  manner  as  possible  a  description 
of  the  most  available  agents  that  may  be  successfully  and  safely 
employed  as  anassthetics. 

Second.  To  present  the  chief  chemical  tests  of  the  purity  of 
each  substance  considered,  with  its  composition,  physical  char- 
acters and  medical  properties. 

Third.  To  exhibit  the  best  methods  of  administering  the 
various  anaesthetics,  to  give  careful  directions,  and  to  state  the 
precautions  to  be  taken  to  avoid  risk  to  the  life  of  the  patient. 

Fourth.  To  note  the  personal  experience  of  the  author,  his 
assistants  and  friends,  with  angesthetics  and  the  various  forms 
of  inhalers  in  use,  with  a  selection  of  the  most  approved,  not 
withholding,  however,  the  objections,  but  noting  the  experi- 
ments of  other  reliable  investigators. 

Fifth.  To  compare  the  relative  mortality  from  all  the  anaes- 
thetics now  employed,  endeavoring  to  assist  the  reader  in  form- 
ing a  fair  and  candid  opinion  of  this  most  important  subject, 
which  has  for  so  long  a  period  occupied  the  attention  of  the 
public  as  well  as  the  medical  profession. 

1502  Walnut  Street,  Philadelphia, 
March,  1878. 


TABLE  OF  CONTENTS. 


PART    FIRST. 

CHAPTEE  I. 

PAGE 

History  of  Ancient  and  Modern  Anesthetics — The  First  Dis- 
coverer of  Nitrous  Oxide, 25-31 

CHAPTER  11. 

The  Discovery  of  Special  Anaesthetics — Ether,  Chloroform — 
The  True  Value  of  Anaesthetics — Theories  of  the  Manner  in 
which  Anaesthetics  Produce  Their  Effects — Local  Ansesthetics 
— Cocaine — Eucaine— Eucaine  Hydrochlorate, 31-40 


PART    SECOND. 


CHAPTEE  III. 

Nitrous  Oxide  Gas,  its  Mode  of  Preparation  and  Chemical  Com- 
position— Gasometer  for  Preparing  Xitrous  Oxide  Gas — Iron 
Eetorts  for  Making  Protoxide  of  Xitrogen  Gas— Inhalers- 
Thomas'  Nitrous  Oxide  Inhaler— Nitrous  Oxide  Inhaler- 
Inflatable  Face  Piece  for  Inhaler— An  Improved  Nitrous 
Oxide  Gasometer — An  Apparatus  for  Administration — Liquid 
Nitrous  Oxide— A  Seamless  Gas  Cylinder— Wall-Bracket  for 
Gas  Cylinders— Surgeon's  Case— Surgeon's  Upright  Case — 
The  Proper  Method  of  Administering  Nitrous  Oxide  Gas 
as  an  Anaesthetic — Clover's  Apparatus  for  Nitrous  Oxide  and 


XIV  TABLE    OF    CONTENTS. 

PAGE 

Ether — The  Physical  Properties  and  Physiological  Action 
of  Nitrogen  Monoxide — Nitrous  Oxide — Experiments  with 
Nitrous  Oxide  by  the  late  Drs.  McQuillan,  J.  D.  Thomas,  and 
the  Writer — The  Spectroscope  and  its  Eelations  to  Anaesthetics 
— Experiments  with  the  Spectroscope — Additional  Facts  in 
Reference  to  the  Physiological  Action  of  Nitrous  Oxide —  • 
The  Phenomena  of  So-called  Asphyxia  of  Nitrous  Oxide 
Narcosis — Conclusions  of  Experiments  upon  the  Brain  and 
Spinal  Cord  with  Nitrous  Oxide  Gas — The  Eeflexes  under 
Nitrous  Oxide — The  Induction  of  Anaesthesia  in  Heart  Failure 
from  Nitrous  Oxide — Eeviewiug  Nitrous  Oxide  Experiments 
— Experiments  with  Nitrous  Oxide  on  the  Kidney — Sphygmo- 
graphic  Tracings  from  Patients  Under  the  Influence  of 
Nitrous  Oxide  Gas — On  Blood  Alterations  by  Anaesthetic 
Agents — Conclusions — Nitrous  Oxide  in  General  Surgery — 
Nitrous  Oxide  and  Oxygen  as  an  Anaesthetic — Hewitt's  Ap- 
paratus— Hewitt's  New  Simplified  Portable  Apparatus  for 
Administering  Nitrous  Oxide  and  Oxygen — Important  To 
Examine  Oxygen  Inlets — Lubricating  Inner  Drum — To  Ex- 
amine Valves  in  Delivery  Tubes — On  Dr.  Hewitt's  Method 
■of  Using  Nitrous  Oxide  and  Oxygen  as  an  Anaesthetic — Con- 
clusion of  Dr.  Hewitt — Observations  on  the  Statements  and 
Abstracts  from  Monograph  of  Dr.  H.  C.  Wood — Experiments 
with  Nitrous  Oxide  Gas  and  Nitrogen  Gas — Oxygen  and  Car- 
bonic Acid — The  After-Effects  of  Nitrous  Oxide  Gas — Acci- 
dents in  Extracting  Teeth  Under  Nitrous  Oxide — Adminis- 
tering Nitrous  Oxide  to  Children — Deaths  Under  Nitrous 
•Oxide — Died  in  a  Dentist's  Chair — Deaths  from  Nitrous  Oxide 
Gas — Therapeutic  Application  of  Nitrous  Oxide — Therapeu- 
tics of  Nitrous  Oxide  Gas  According  to  Dr.  A.  M'Lane  Ham- 
ilton— Dr.  Colton  on  the  Safety  in  Disease  of  Nitrous  Oxide 
Gas — Disease  of  Lungs,  Heart  Disease,  In  Chorea,  Hysteria, 
Epilepsy,  Hysteria,  Asthma,  Paralysis,  Cases  of  Epilepsy — 
Nitrous  Oxide  and  Oxygen  as  an  Anaesthetic  in  Labor — The 
Field  Widening  for  the  Use  of  Nitrous  Oxide  Gas — Citations 
•of  a  Few  Chronic  Cases  Treated  by  Nitrous  Oxide  and  Oxy- 
gen— On  Insanity  or  Mental  Disturbance  Following  an  Opera- 
tion Where  a  Prolonged  Use  of  an  Anaesthetic  had  been  Em- 
ployed— On  the  Action  of  Nitrous  Oxide,  and  of  the  Mixture 
.     of  Nitrous  Oxide  and  Oxygen — Experiments  on   Dogs,  by 

H.  C.  Wood,  M.D., 41-134 


TABLE    OF    CONTENTS.  XV 


PART    THIED. 


CHAPTEE  IV. 
(CHO.CHOH.) 


PAGE 


Alcohol,  Different  Kinds — The  Alcohol  Recognized  by  the  U. 
S.  Pharmacopoeia— Absolute  and  Dilute  Alcohols — The  Alcohol 
of  Whiskey,  Wine  and  Brandy — Amylic  Alcohol — The  Phys- 
iological Action  of  Alcohol — The  Influence  of  Alcohol  on  the 
Kidney  and  Liver — Strychnine  in  Chronic  Alcoholism — The 
Toxic  Action  of  Alcohol  on  the  Heart  in  Moderate  Doses — 
Heat-producing  and  Waste-preventing  Action  of  Alcohol — 
Conclusions  as  to  the  Physiological  Action  of  Alcohol — Alcohol 
as  an  Anesthetic — Views  of  Eichardson,  Link  and  Others — 
Toxicology  Treatment  of  Acute  Alcohol  Poisoning,    .     .     .  135-147 

CHAPTEE  V. 

Ethyl  Ether,  the  Ether  of  Commerce — Ether  Fortior,  how 
Manufactured — Chemical  Eeactiou — Chemical  and  Physical 
Properties — Determination  of  Purity — The  Inhalation  of 
Ether — Etherization  Ansesthetic,  Various  Stages — Effects 
upon  Different  Individuals — Precautions  to  be  Employed 
Before  and  After  Using  Ether  as  an  Aneesthetic — Treatments 
of  Dangerous  Symptoms — Means  to  be  Employed  in  Heart- 
failure,  Collapse  or  Shock — Cases  in  which  Ether  Should  Not 
be  Employed  as  an  Antesthetic — Physiological  Action  of 
Ether — Experiments  with  Atropine — Experiments  on  the 
Heart  and  Pulse  Shown  by  Sphygmographic  Tracings — The 
Action  on  the  Brain,  Heart  and  Circulation — Closed  Cone  as 
Inhaler — Dr.  Allis's  Improved  Inhaler,  its  Various  Forms 
for  Ether — Clover's  Small  Portable  Ether  Inhaler — The  Cone 
and  its  Modifications — Advantages  of  the  Cone — Dr.  Lente's 
Inhaler — Ormsby  Inhaler — Hearn,  Cheatham,  Parkinson, 
Codman  and  Shurtleff,  for  Ether — Souchon's  Auxiliary  In- 
jector for  uninterrupted  Ansesthesia  in  Operations  on  the 
Face  and  Mouth,  for  Ether  and  Chloroform — Mixture  of 
Chloroform  and  Ether  the  one  which  he  Prefers — Proportions 
of  Ansesthetic  Vapor  and  Air  at  each  Compression  of  the 
Bulb,  by  Hermann  Fleck,  Ph.D.,  Instructor  of  Chemistry  in 
the  Harrison  Chemical  Laboratory  of  University  of  Pennsyl- 


XVI  TABLE    OF    CONTENTS. 

PAGE 

vania — Conclusions — On  Tissue  Changes  in  Cases  of  Sec- 
ondary Death  After  Ether,  by  Drs.  H.  C.  Wood  and  William  S. 
Carter — It  is  Possible  to  Have  Death  Produced  by  an  Anaes- 
thetic some  time  after  the  Cessation  of  the  administration  and 
the  Eeturn  of  Consciousness,  by  Drs.  Wood  and  Carter — 
Ether  by  the  Rectum — The  Chief  Danger  from  the  Admin- 
istration of  Ether  per  Rectum — Apparatus  for  the  Adminis- 
tration of  Ether  per  Rectum — Internal  Administration  of 
Ether  in  Gout,  Spasm  of  Stomach,  Heart  or  Intestines,  Tape 
Worm,  Hysteria,  Post-Partum  Haemorrhage — Sciatica  by  the 
Subcutaneous  Injection  of  Ether — Asthma,  Coryza,  Obstinate 
Hoarseness — Ether  as  an  Expectorant — Chorea,  Nervous 
Aphonia,  Diphtheritic  Angina  or  Pseudo-Membranous 
Croup — Whooping-cough — Ether  Intoxication — Cases  of — 
The  Use  and  Advantages  of  Ether  in  Vivisections — Vivisec- 
tions with  Ether  and  Chloroform, 148-200 

CHAPTER  VI. 

Ethers  with  Anaesthetic  Properties :  Acetic,  Formic,  Methylic, 
Bichloride  of  Methylene,  EthyJene,  Bromide  of  Ethylene, 
Chlorhydrin,  Bromoform,  its  use  in  Whooping-cough,  Butyl 
Chloride,  Methyl  Iodide,  Aldehyde,  Acetic  or  Ethylic— Use 
of  Pai-aldehyde  in  Sleeplessness — Chloral  Hydrate,  Its  Use 
and  Abuse — On  the  Value  of  Oxygen  Gas  in  Prolonged  Oper- 
ations in  which  Ether  Has  Been  Administered  as  an  Anaes- 
thetic—Ether or  Chloroform,  Which  ?— Danger  of  Ether — 
Excessive  Secretion,  Asphyxia — The  Danger  of  Nephritis, 
Nausea  and  Vomiting — Advantages  and  Dangers  of  Chloro- 
form :  Non-inflammable — More  Agreeable  to  Patient,  More 
Enduring  Anaesthetic  Effect,  Little  Increase  of  Mucous 
Secretion,  Easier  of  Administration— Dangers,  They  Are  Im- 
mediate, if  the  Patients  do  not  Die  During  the  Administra- 
tion they  are  Comparatively  Safe— Nearly  Fifty  Per  Cent,  of 
Deaths  by  Chloroform  Occur  at  the  Outset  of  the  Adminis- 
tration—Chief Danger  of  Chloroform  is  Paralysis  of  Nervous 
System  Governing  Circulation  and  Respiration — Centres 
Taken  by  Surprise — Treacherous  Irregularities  of  the  Heart 
— Action  in  Chloroform,  as  Regards  its  Beats,  is  Especially 
Ominous — Patients  who  Breathe  Irregularly  Should  be  Anaes- 
thetized with  the  Utmost  Care — A  Rest  to  the  Patient— On 
Blood — Alterations  by  Ether,  by  John  C.  DaCosta,  M.D. — 
Haemoglobin,  Heematoglobin,  Haemocrystallin,  Definition  of 


TABLE    OF    CONTENTS.  Xvii 

PAGE 

Each— The  Amount  in  Mau,  in  Woman— The  Diminution  of 
the  Amount  of  Oxyhaemoglobin- Alterations  of  the  Shape  of 
the  Corpuscles  and  Diminution  of  Their  Number— Detail  of 
Twenty-eight  Cases  and  Conclusions — The  Influence  of  Anses- 
thetics  on  the  Kidneys,  More  Especially  Ether  and  Chloroform, 
Dr.  H.  C.  Wood  and  his  Son.  Dr.  George  B.  Wood— Choice  of 
Anaesthetic  for  Ureemic  Patients — Observations  of  the  late  Dr. 
Emmet,  and  William  F.  Norris — Dr.  Lawson  Tait,  Eemarkable 
Case  in  which,  the  Ureters  Being  Exposed,  it  was  found  that 
the  Continuous  Administration  of  Ether  Prevented  the  Secre- 
tion of  Urine — Experiments  on  Dogs,  it  was  found  by  Dr. 
George  B.  Wood  that  During  the  Administration  of  Ether  as  an 
Aneesthetic  the  Kidneys  Became  Markedly  Congested — The 
Cells  and  Tufts  and  Corresponding  Tubules  were  Those 
Primarily  Afiected— The  Failure  of  Fueter  to  Detect  Changes 
in  the  Kidneys — Testimony  of  Dr.  Guiteras  Corroborative  of 
the  Eesults  of  Dr.  Wood  s  Cases, 200-226 

CHAPTEE  VII. 

Hydrobromic  Ether  or  Bromide  of  Ethyl — Properties— Mode 
of  Preparation — Description  of  Physical  and  Chemical  Qual- 
ities—Physiological Action — Experiments  on  Animals — Use 
as  an  Ansesthetic,  Verneuil  and  Terrillon — Care  Necessary  in 
its  Use— Mode  of  Employment — Use  of  by  Dr.  Koellicker — 
M.  Bazy  on  Vomiting,  which  Earely  Followed  when  Em- 
ployed Alone — Professor  Wood's  Eecent  Views  on  this  Sub- 
ject— Dr.  Gillis's  Claims  for  it— Proceeding  of  the  Academy 
of  Medicine  of  Paris— Case  of  Sudden  Death  Eeported  by  M. 
Suarez  de  Mendoza  of  Angers,  and  Eemarks,  also  Those  of 
M.  Terrier  before  the  Societe  de  Chirurgie — Some  Eecent 
Observations  on  Mixtures  of  Bromide  of  Ethyl — Their  Dan- 
ger—Chemical Examination  of  One  of  Them— Examples  of 
Impure  Specimens  of  Bromide  of  Ethyl,  by  Professor  Jungk 
— Deaths  from  the  Same,  by  Dr.  Levis,  of  Philadelphia,  Dr.  M. 
Sims,  of  New  York — Professor  E.  E.  Montgomery's  Opinion 
of  the  Value  of  Ethyl  Bromide  in  Obstetrics— Continued 
Use  of— Extensively  Employed  by  the  Dentists  of  Germany,  227-238 


XVlll  TABLE    OF    CONTENTS. 


PART    FOURTH. 


CHAPTER  VIII. 

Chloroform — Mode  of  Preparation — An  Improved  Chloroform 
— Purified  Chloroform — Mode  of  Administering  Chloroform 
in  the  United  States,  England,  France — Inhalers  of  Various 
Kinds — The  Scotch  Method  in  Detail — Remarks  on  the  Con- 
clusions of  the  Hyderabad  Commission — Report  of  Cases  in 
which  Chloroform  Caused  Death  by  Paralyzing  the  Heart 
First — Lancet    Commission    on    Anaesthetics — Direction    of 
Inquiry  by  Dr.  Buxton  and  His  Classification  of  Cases  of 
Deaths  from  Chloroform — Geographical  Distribution  of  Fatal- 
ities from  Chloroform — Deaths  in  the  South,  in  Scotland — 
Methods  Employed  for  Administering  Chloroform  in  which 
Death  Followed — Causes  Assigned  for  Death  by  Chloroform 
— The  Amount  of  Chloroform  in  100  Cubic  Inches  of  Satu- 
rated Mixture — Air  and  Chloroform  at  Different  Tempera- 
tures—Snow's Tablets — Pupillary  Phenomena  Observed   in 
the  Various  Styles  of  Chloroform  Narcosis — Dr.   MacEwen, 
of  Glasgow,  on  the  Mistakes  of  Young  Operators  in  Touching 
the  Cornea — Stages  of    Chloroform  Ansesthesia — Nelson  on 
the  Pupil   as  a  Guide  in  Giving  Chloroform — Toxicological 
Effects  of  Chloroform — Howard  on  Raising  the  Epiglottis — 
The  Treatment  of  Arrested  Respiration,  by  Drs.  Martin  and 
Hare,   on  Free  and  Patulous  Nostrils — Conclusions — Addi- 
tional Facts  as  to  Treatment  of  Dangerous  and  Fatal  Symp- 
toms of  Chloroform  as  an  Ansesthetic— Sylvester's  Method 
of  Artificial  Respiration  on  the  Epiglottis  in  Chloroform — 
Accidents  by  Dr.  A.  E.  Prince,  New  York— Resuscitation  by 
Anal  Dilatation,  by  Dr.  L.  C.  Grosvenor,  of  Chicago,  III. — 
Dr.  Brunton  on  Chloroform,  in  the  Discussion  of  Dr.  Wood's 
Paper  on  Anaesthetics,  Before  the  Berlin  Congress — Recent 
Views  in  Regard  to  the  Action  of  Chloroform,  by  Drs.  Gas- 
kell  and  Short,  of  the   University  of  London — Dr.  Brunton 
in  His  Publication   Giving   Away  the   Whole  Case  of  the 
Hyderabad  Commission — Dr.  Wood's  Opinion  and  the  Au- 
thor's, Resuscitation  by  Lingual  Traction — Dr.  J.  Lawrence 
Hamilton's  Views  on  Professor  Laborde's  labors — Dr.  Bowles 
Has  Shown  that  in  Apparent  Death  from  Drowning,  in  the 
Supine  or  Horizontal  Position,  the  Paralyzed  Tongue,  by  Let- 


PAGE 


TABLE    OF    CONTENTS.  XIX 

PAGE 

ting  its  Base  Drop  Backwards,  Thereby  Blocks  up  the  Pharynx 
— Dr.  Hunter  oa  Eesuscitation  by  Means  of  his  Specially 
Constructed  Bellows — Dr.  Champney's  Experiments — Rhyth- 
mic Tractions  of  the  Tongue  in  Accidents  and  in  Asphyxia 
from  Chloroform — M.  Filiget's  Case — Dr.  Dennea,  Neoplasm 
of  the  Larynx — Professor  Masse's  Case — Dr.  Meniere's  Case, 
and  others,  on  the  Influence  of  Chloroform  in  Producing 
Tissue  Changes,  such  as  Fatty  Degeneration  of  the  Heart, 
Diaphragm  and  Other  Striated  Muscles,  and  also  of  the  Par- 
enchyma of  the  Liver  and  Kidneys,  by  Drs.  Wood  and  Car- 
ter— Perils  of  Chloroform  Administered  in  Dental  Opera- 
tions— Chloroform  Given  Improperly — The  Employment  of 
Nitrite  of  Amyl— Want  of  Success, 239-292 

CHAPTER  IX. 

History,  with  Conclusions,  from  1888  to  1895  Inclusive — The 
Pulse  During  Chloroform  Ausesthesia — Conclusive  Statements 
and  Experiments  of  Dr.  McWilliam  in  answer  to  Dr.  Lawrie, 
On  the  Importance  of  Long-continued  Artificial  Respira- 
tion after  Chloroform  Asphyxia,  in  India — Conclusions  as 
to  Chloroform — Table  of  Deaths  from  Chloroform  and  Ether 
since  the  Hyderabad  Commission — Notes  Referring  to  the 
Table — Four  Deaths  from  Chloroform  in  Reading,  Pa.,  and  . 
Vicinity — Note  5,  Death  from  Chloroform  of  a  Peculiarly 
Painful  Character — Note  6,  Deaths  from  Ether — Case  of 
Death  from  Ether  of  Colonel  E.  F.  Shepard,  of  New  York — 
The  Proper  Method  of  Making  Hospital  Reports  in  Cases  of 
Anaesthesia — Records  and  Report  of  Autopsy — The  Deathly 
After-Eff'ects  of  Chloroform,  by  Dr.  C.  Thiem  and  Dr.  P. 
Fischer — Observations  and  History  of  Original  Experiments 
Prior  to  1S80 — Primary  Syncope  from  Chloroform,  by  Dr. 
Robert  Kirk,  of  Edinburgh,  with  Cases, 293-329 

CHAPTER  X. 

Chloroform  in  Dental  Surgery,  by  Frederic  Hewitt,  M.D. — I. 
Introduction — II.  The  Lines  Upon  Which  the  Inquiry  was 
Conducted— III.  Classification  and  Analysis  of  Cases— Table 
— Deaths  in  Connection  with  General  Anaesthetics  Adminis- 
tered for  Dental  Operations  in  Great  Britain,  1880-1894  In- 
clusive, =  37— Sex — Age— General  Condition— Preparation- 
Posture— Flexion  of  the  Head  upon  the  Sternum — Method 
of   Administration    and    Quantity    of    Chloroform    Used — 


XX  TABLE    OF    CONTENTS. 

PAGE 

Nature  of  Operation — Relation  of  Dangerous  Symptoms  to 
Operation — Phenomena  During  Administration  and  Opera- 
tion—Fatal Phenomena— Post-Mortems, 329-338 

CHAPTER  XL 

Dr.  Kreutzniann,  Use  of  Mixture  of  Ether,  Chloroform  and  Oxy- 
gen in  San  Francisco  as  Early  as  August,  1887 — Dr.  Neudor- 
fer,  of  Vienna,  Who  Claims,  on  Theoretical  G-rounds,  that  its 
Employment  is  Entirely  Without  Danger — Oxygen  as  an 
Antidote  to  Chloroform  Cases,  by  Dr.  Simeon  Abrahams,  of 
New  York — Dr.  Loyssel's  Experiments  with  Pure  Oxygen  in 
Recalling  Patients  to  Life  When  all  Else  Mas  Failed — Dr. 
H.  L.  Northrop,  of  Philadelphia,  His  Reasons  for  the  Admin- 
istration of  Oxygen  and  Chloroform — Oxygen  was  an  Anti- 
dote to  Chloroform — Oxygenated  Chloroform  Apparatus — 
Chloroform  and  Oxygen,  Use  of  it  in  Hospital  Practice — 
Restricted  to  Children,  Alcoholics  and  Short  Operations — 
Ether  has  Been  Given  More  Frequently  than  any  Other 
Anaesthetic — Use  by  Prof.  Montgomery — Oxygen  Gas-Inhal- 
ing Apparatus  of  the  S.  S.  White  Co., 338-351 

CHAPTER  XII. 

Mixed  Anaesthetics — Report  of  Chloroform  Committee  Med. 
Chir.  Soc,  London — Their  Superiority  in  Point  of  Safety — 
M.  Perrin's  First  Death — Snow's  Opinion — Second  Case  Re- 
ported by  Dr.  R.  Crockett — The  Composition  of  the  Various 
Mixtures  by  the  Committee — The  Introduction  of  Alcohol, 
by  Dr.  Harley — Dr.  Sansom's  Mixture — What  are  the  Objec- 
tions to  the  Mixtures? — Boiling-Points  of  the  Agents  Em- 
ployed as  Anaesthetics — Experiments  of  Drs.  L.  and  C.  S. 
Turnbull  to  Determine  the  Time  Required  for  Evaporating 
Substances  on  Tissue  Paper — Danger  from  the  Water  Pro- 
duced from  Ether — The  Inhalation  of  Chloroform  and  Ether 
a  Cause  of  Aural  Disease — Brief  Extract  of  Experiments 
with  a  Mixture  of  Ether  and  Bromide  of  Ethyl  and  Chloro- 
form, Performed  by  Drs.  Reichert,  Turnbull  and  Thomas — 
Mixed  Anaesthetics — Opinion  of  Dr.  Wood — The  Late  Dr. 
Washington  W.  Atlee's  Mixture — Recent  Death  from  a  Mix- 
ture of  Ether  and  Chloroform — Other  Deaths  from  the  Mix- 
ture— How  Shall  Nitrous  Oxide  Gas  and  Ether  be  Adminis- 
tered? by  Dr.  Frederick  W.  Silk,  of  London— Mixtures  of 
Nitrous  Oxide,  Ether,  Chloroform  and  Alcohol  for  Inhala- 
tion,        351-370 


TABLE    OF    CONTENTS.  XXI 

PART    FIFTH. 

CHAPTEE  XIII. 

PAGE 

Local  Anaesthesia  and  Anaesthetics — Various  Local  Anaes- 
thetics and  the  Eemarkable  Effects,  According  to  Dr.  Lieb- 
reich — Electricity  as  a  Local  Anaesthetic,  Alone  or  with 
Cocaine — Bonwell's  Method — Dr.  I.  Corning,  of  New  York, 
Perforating  of  the  Skin,  use  of  Cocaine  Solution  and  Elec- 
trode, with  the  use  of  Compression — Electrical  Osmosis  for 
the  Treatment  of  Living  Dentine,  by  Henry  W.  Gillett,  M.D., 
of  Newport,  E.  I. — Definition  of  the  Term — Use  of  the  Se- 
lector Experiments,  with  Eesults  Obtained,  by  Dr.  Wm.  I.  Mor- 
ton, New  York,  with  Guaiacol — Conclusions — Eesults  Ob- 
tained by  Dr.  E.  C.  Kirk,  of  Philadelphia,  and  W.  I.  Younger 
— The  Excellent  Eesults  from  the  Use  of  Guaiacocine,  .     .  371-383 


PART    SIXTH. 

CHAPTEE  XIV. 

Local  Anaesthetics — Coca  Plant  Leaves — Preparations,  More 
Especially  the  Wine — Its  Active  Principle — Cocaine;  its 
Action  as  a  Stimulant  of  the  Nervous  System  and  Eetarder 
of  Metamorphosis — Cocaine  and  its  Salts  Solutions — Tests  of 
Purity — Cocaine  Inebriety, 384-389 

CHAPTEE  XV. 
Experiments  with  Cocaine  on  Animals — The  Physiological  Ac- 
tion of  Cocaine  upon  the  Animal  System,  More  Especially 
upon  Dogs — Experiments  with  Professor  Eeichert,  on  the 
Action  of  Cocaine  on  the  Eye — Fatal  Dose  of  Hydrochl orate 
of  Cocaine, 389-395 

CHAPTEE  XVI. 
Cocaine  Inebriation  and  Habit — Treatment — Deaths  from  Co- 
caine— Morbid  Changes — Viau's  Method  of  Employing  Phenic 
Acid  and  Cocaine — Schleich's  Infiltration  Method  of  Using 
Local  Anaesthesia  by  Cocaine — Used  in  Inflamed  Parts — Cau- 


XXll  TABLE    OF    CONTENTS. 

PAGE 

tion — Formulas  Advocated  by  Schleich — Formatiou  of  the 
Cutaneous  Wheals — Notes  on  the  Danger  of  Sepsis  in  Ender- 
mic  Injection — Infiltration  Aufesthesia — On  the  Preparation 
of  the  Solution — Soluble  Compressed  Tablets — On  the  Use  of 
Cocaine  upon  the  Nasal  Mucous  Membrane  Prior  to  and  Dur- 
ing Anfesthesia,  by  Eosenberg  and  Gerster, 395-412 

CHAPTER  XVII. 

On  the  Use  of  Cocaine  in  the  Teeth,  Nose,  Throat  and  Eyes — 
Was  it  Cocaine  Poisoning? — The  Use  of  Cocaine  in  the  Nose 
and  Throat — Cocaine  in  the  Ear — Deaths  from  Cocaine,     .  412-421 

CHAPTER  XVIII. 

Therapeutics  of  Cocaine — Gastritis  Produced  by  an  Irritating 
Poison  Treated  by  Cocaine  —  Certain  Affections  of  the 
Stomach — Cocaine  in  Persistent  or  Uncontrollable  Vomit- 
ing— Cocaine  in  Lavage  or  Gavage — In  Boulimic  or  Insatiable 
Hunger — Tetanus  Treated  by  Morphia  and  Cocaine — Cocaine 
in  Skin  Disease,  in  the  Treatment  of  Chilblain,  in  Intense 
Itching  of  the  Skin,  in  Burns,  in  Anal-vulval  Pruriency  or 
Painful  Herpes,  in  Cracked  Nipples,  in  Acute  Catarrh,  Coryza 
or  Cold  in  the  Head,  in  Hay  Fever  or  Rose  Cold — Cocaine  and 
Phosphate  of  Lime  in  Laryngeal  Tuberculosis,  in  Whooping 
Cough — Cocaine  and  Resorcin  in  Whooping  Cough — Mixture 
of  Cocaine,  Glycerine  and  Carbolic  Acid  in  Cough  and 
Chronic  Pharyngitis — Cocaine  for  the  Same  by  Insufflation 
and  Inhalation,  in  Paroxysmal  Sneezing,  Rose  Cold  or  Hay 
I*ever,  in  Asthma, 422-429 

CHAPTER  XIX. 

Cocaine  in  Catarrhal  Conjunctivitis  and  Clyclitis,  in  Gonor- 
rhoeal  Ophthalmia — Cocaine  and  Atropia  for  Iritis — Use  of 
Hydrochlorate  in  Ear  Disease — Eucaine  Hydrochlorate ;  its 
Physiological  Action,  Local  Action,  General  Action  of  the 
Drug  as  a  Local  Anaesthetic  in  the  Eye — Eucaine  and  Co- 
caine ;  Directions  for  its  Use  in  Dentistry — Report  of  Cases 
in  Minor  Surgery, 429-441 

CHAPTER  XX. 
Chloride  of  Ethyl ;   its  General  Character  and  Chemical  and 
Physical    Properties — Discoveiy — Experiments   of  Clover — 
Mono-Chlorethane— Wigger's  Anaesthetic  Ether— Chloride  of 


TABLE    OF    CONTENTS.  XXlll 

PAGE 

Ethyl  as  a  Local  Anaesthetic— Objections  to  Powerful  Re- 
frigerative  Agents— Experiments  with  Chloride  of  Ethyl  and 
Peutal  by  Dr.  H.  C.  Wood  and  David  Cerna,  M.D.— Com- 
pounds, Phenol,  Camphor,  Menthol,  and  Eesorcin— Antipy- 
rine  as  a  Local  Ansesthetic, 441-453 

CHAPTER  XXL 

Local  Anesthetics— Oil  of  Eucalyptus,  Ether,  Ehigolene, 
Methyl  and  its  Chlorides,  Hydrastine,  Homatropiue  and 
Ephedrine,  Chlorohydrate,  Brucine,  Apomorphine,  Hydro- 
chloras,  Erythrophleiue  or  Haya-Caffeine— Caffeine,  Helle- 
borine,  Canadol,  Menthol,  Iodoform,  lodol,  Bromide  of  Ethyl, 
Bromide  of  Potassium,  Ethyliodide,  Chloral  and  Camphor 
as  a  Local  Anaesthetic— Piper  Methysticum  and  the  Cocaine 
Molecule,  Naphthaline,  Quinine,  Antipyretic  and  Anesthetic 
—Thymol,  Sulphonal,  Pyoktanin,  Acid  Trichloracetic,  Aristol, 
Urethane,  Trional  and  Tritronal  Hypnal, 454-487 


PART    SEVENTH. 

CHAPTER  XXII. 
A  Supplement  for  the  Student  to  Commit  to  Memory— Anes- 
thesia Derivation— Artificial  Anesthesia— Ether— Chloro- 
form—Mixed  Anesthesia— Nitrous  Oxide— The  Most  Promi- 
nent Local  Anesthetics- Antidotes  to  Cocaine— Precautions 
to  be  Taken  in  Administration  of  Chloroform,  Ether  and 
Nitrous  Oxide— Electricity  in  Resuscitation,  Asphyxia, 
Blood-Pressure,  Cardiac  Failure— x^dditional  Means  of  Resus- 
citation During  the  Administration  of  Anesthetics— Konig's 
and  Kelly's  Methods, 488-499 

CHAPTER  XXIII. 
Experiments  of  Dr.  H.  C.  Wood  and  Dr.  Hobart  A.  Hare  in 
Reply  to  the  Hyderabad  Commission,  February,  1890— A 
Study  of  the  Influence  of  Chloroform  Upon  the  Circulation, 
by  Dr.  Hare  and  Dr.  E.  Q.  Thornton — Lawrie  and  the  Hy- 
derabad Chloroform  Inhaler — Krohne  and  Seseman's  Indica- 
tor Respirator  Attachment;    This  they  have  also  Attached 


XXIV  TABLE    OF    CONTENTS. 

PAGE 

to  Junker's  Inhaler — Dr.  Guereu  on  Prevention  of  the  Ac- 
tion of  Chloroform  on  the  Heart — Dr.  W.  I.  Fleming  on 
Proneness  of  Dogs  to  Succumb  to  Chloroform — Dr.  John 
Freeman,  of  Bristol,  England,  Eeasous  for  the  Greater  Safety 
of  Ether  as  an  Anaesthetic, 500-509 

CHAPTER  XXIV. 

Ansesthetics — Their  Value  in  Disease — Which  to  Avoid  and 
Those  to  Employ — In  Disease  of  the  Heart,  in  Disease  of  the 
Lungs,  in  Disease  of  the  Kidneys — What  to  do  First  in  Case 
of  Danger — In  What  Class  of  Cases  Can  Chloroform  be  Em- 
ployed with  Safety  in  Obstetrics — Opinions  of  the  Late  Dr. 
Fordyce  Barker,  of  New  York,  and  Dr.  John  N.  Upsher,  of 
Eichmond,  Va., 509-515. 

CHAPTEE  XXV. 
The  Legal  Eesponsibility  of  Physicians  in  the  Administration 
of  Ansesthetics — Opinions  of  the  author,  Daniel  S.  Eiddle, 
Esq.,  of  New  York ;  Coroner  Ellinger,  Max  F.  Eller,  Esq. — 
M.  Dolbeau,  of  Paris;  His  Experiments  with  Chloroform  on 
Patients  When  Asleep — Case  in  Philadelphia  of  Surgeon 
Dentist — Cases  in  France,  England  and  the  United  States — 
Chloroform  as  a  Poison — The  Chloroform  Habit,  or  Chloro- 
form by  the  Mouth — Hypnotic  Anaesthesia  and  its  Analogous 
States  in  their  Various  Aspects — Hypnotism  as  an  Anaesthetic 
— Therapeutic  Hypnotism — Eeport  of  the  Committee  of  the 
British  Medical  Association  to  Investigate  the  Nature  of  the 
Phenomena  of  Hypnotism — Its  Value  as  a  Therapeutic  Agent, 
and  the  Propriety  of  Using  it, 516-538 


ARTIFICIAL  ANAESTHESIA. 


PART    FIRST. 


CHAPTER    I. 

History  of  Ancient  and  Modern  Aiisesthetics. 

The  ancient  Greeks,  it  is  stated,  possessed  a  plant  called 
mandrake,  wliicli  belonged  to  the  same  family  as  belladonna  or 
deadly  night-shade.  From  the  root  of  this  plant  was  extracted, 
by  means  of  wine,  a  narcotic  which  was  employed  by  them  as 
an  anaesthetic.  Lucius  Apuleius,  who  lived  about  160  A.D. , 
and  of  whose  works  eleven  editions  were  published  in  the  four- 
teenth and  fifteenth  centuries,  says,  "  that  if  a  man  has  to  have 
a  limb  mutilated,  sawn  or  burnt,  he  may  take  half  an  ounce  of 
mandragora  wine,  and  whilst  he  sleeps  the  member  may  be  cut 
off  without  pain  or  sense."  To  prove  that  this  was  true.  Dr. 
B.  W.  Richardson,  of  London,  after  a  lapse  of  five  centuries, 
obtained  a  fine  specimen  of  mandragora  root,  and,  afcer  making 
wine  from  it  and  testing  it,  found  it  was  a  narcotic  having  pre- 
cisely the  properties  that  were  anciently  ascribed  to  it.  He  dis- 
covered that  in  animals  it  would  produce  even  the  sleep  of  Ju- 
liet, not  for  thirty  or  forty  hours,  a  term  that  must  be  accepted 
as  a  poetical  license,  but  for  the  four  hours  named  by  Dioscori- 
des  ;  and  that,  on  awakening,  there  was  an  excitement  which 
tallied  with  the  same  phenomenon  that  was  observed  by  the 
older  physicians.  Another  fact  was  noticed  by  the  ancients — 
that  many  volatile  substances  acted  more  promptly  when  in- 
haled than  when  taken  into  the  stomach,  and  the  first-named 
form  of  medication  was  employed  in  Greece,  Rome  and  Arabia. 


26  ARTIFICIAL    ANAESTHESIA. 

By  the  works  published  in  those  countries  the  knowledge  of  these 
facts  was  extended  to  other  parts  of  the  world.  "He  has  eaten 
mandrake  "  was  said  of  a  very  indolent  and  sleepy  man,  from 
the  narcotic  and  stupefying  properties  of  the  plant,  well  known 
to  the  ancients. 

Cleopatra. — "  Give  me  to  drink  mandragora 

That  I  might  sleep  out  this  great  gap  of  time 
My  Anthony  is  away." 

— Shakespeare,  "Anthony  and  Cleopatra,"  act  i.,  scene  5. 

In  China,  in  ancient  times,  the  word  ma-yo  meant  not  only 
Indian  hemp  but  anaesthetic  medicine  ;  other  substances  besides 
hemp  entered  into  the  benumbing  recipes,  such  as  the  datura, 
a  solanaceous  or  soothing  plant,  probably  identical  with  the 
atropia  or  mandragora ;  also  aconite,  hyoscyamus,  etc.  A  wine 
of  mandragora  was  used  by  the  Romans  to  relieve  the  sufferings 
of  the  crucified,  and  was  employed  (down  to  the  thirteenth  cen- 
tury) as  a  surgical  anaesthetic.  Some  of  these  drugs  form  con- 
stituents of  the  formula  said  to  be  employed  by  kidnappers  of 
children  and  by  robbers ;  consequently  their  sale  or  employment 
is,  at  the  present,  prohibited  in  China.  Dr.  Dudgeon,  of  Pe- 
kin,  writing  in  1877,  gave  a  flat  contradiction  to  the  extrava- 
gant stories  current  in  Europe  respecting  the  skilful  use  made 
by  the  early  Chinese  of  benumbing  drugs,  and  probably  a  more 
exact  acquaintance  with  the  fact  would  show  that  the  practice 
of  Grreece  and  Rome  was  not  less  elementary.  Only  in  modern 
times  and  in  the  light  of  scientific  teaching  was  it  possible  for 
anaesthetics  to  take  their  proper  place  as  helpmates  of  the  sur- 
geon in  his  art  and  as  the  grand  alleviators  of  human  suffering. 

Theodoric,  about  the  year  1298,  gives  elaborate  directions 
how  to  prepare  a  "  spongia  somnifera  "  by  boiling  it  dry  in  nu- 
merous strong  narcotics  and  afterwards  moistening  it  for  inhala- 
tion before  operations. 

Opium  was  also  employed  in  later  years  (prior  to  surgical 
operations),  and  was  found  the  best  narcotic  for  the  relief  of 
pain  and  for  producing  insensibility,  although  not  free  from 
danger. 


MODERN    ANESTHESIA    AND    ANESTHETICS.  27 

History  of  Modern  Aiifs^stliesia  and  Ansestlietics. 

On  September  3,  1828,  M.  Girardin  read  to  the  Academy  of 
Medicine,  of  Paris,  a  letter  addressed  to  His  Majesty,  Charles 
X.,  describing  "surgical  anaesthesia  by  means  of  inhaled 
gases." 

A  strong  impulse  was  given  to  the  study  and  application  of 
the  "diflferent  kinds  of  airs  and  gases"  by  the  discovery  of 
oxygen  by  Priestly  and  Scheele  in  the  middle  of  the  eighteenth 
century,  and  numerous  experiments  were  made  by  physicians 
with  the  new  gas. 

Pneumatic  chemistry  called  into  existence  a  new  branch  of 
therapeutics — pneumatic  medicine,  as  it  is  named  by  its  found- 
ers, who  hoped  to  cure  diseases,  especially  pulmonary  tubercu- 
losis, by  the  inhalation  of  various  gases  and  vapors.  This  has 
been  again  revived  in  our  day.  A  "Medical  Pneumatic  Insti- 
tution "  was  set  up  at  Clifton,  in  1798,  by  Dr.  Beddoes,  which 
had  huge  reservoirs  of  gases  for  the  use  of  patients.  The  cele- 
brated Humphrey  Davy,  who  had  then  just  served  his  appren- 
ticeship, was  appointed  superintendent.  Though  not  success- 
ful in  the  immediate  object  for  which  it  was  founded,  it  was  so 
in  another  sense  ;  for  here  Davy  made  his  researches  concern- 
ing nitrous  oxide  gas.  In  1800  he  discovered  that  when  inhaled 
this  gas  produced  a  peculiar  intoxicating  effect,  together  with  an 
irresistible  propensity  to  muscular  exertion,  and  often  to  laugh- 
ter, whence  its  popular  name  of  "laughing  gas."  He  also  dis- 
covered its  anaesthetic  properties  and  successfully  inhaled  it 
himself  to  relieve  the  pain  of  cutting  a  wisdom  tooth.  He 
made  numerous  experiments  with  the  gas  on  animals.  In  his 
account  of  these  experiments  there  occurs  this  memorable  and 
oft-quoted  sentence  :  "As  nitrous  oxide  in  its  extensive  opera- 
tion appears  capable  of  destroying  physical  pain,  it  may  proba- 
bly be  used  to  advantage  during  surgical  operations  in  which  no 
great  effusion  of  blood  takes  place."  Those  desirous  of  pursu- 
ing the  subject  further  should  read  his  work  entitled,  "Re- 
searches, Chemical  and  Philosophical,  Chiefly  Concerning 
Nitrous  Oxide."  Strange  to  relate,  notwithstanding  their  com- 
pleteness, nothing  came  of  these  remarkable  observations.  Their 
real  import  was  not  understood  until  nearly  half  a  century  later. 


28  ARTIFICIAL    ANAESTHESIA. 

The  modern  practice  of  anaesthesia,  though  it  may  have  been 
benefited  indirectly'  by  these  experiments,  was  not  the  imme- 
diate outcome  of  any  of  them  ;  it  originated  to  a  large  extent 
independently.  The  honor  of  making  this  discovery  rests 
chiefly  with  four  Americans — Horace  Wells,  William  Morton, 
Charles  Jackson  and  Crawford  W.  Long. 

One  winter's  night  in  December,  1844,  a  number  of  the  in- 
habitants of  Hartford,  Connecticut,  assembled  to  hear  a  lecture 
on  nitrous  oxide  and  other  gases  by  Dr.  Colton,  a  well-known 
popular  lecturer,  who  tried  the  effect  of  the  first-named  gas  on 
several  of  the  audience.  Among  those  present  were  Horace 
Wells  and  his  friend,  John  M.  Riggs,  both  dentists  of  that  city. 
They  noticed  that  a  person  under  the  influence  of  the  gas  was  capa- 
ble of  sustaining  a  severe  injury  of  his  leg  without  apparently  feel- 
ing any  pain.  Wells  was  so  impressed  with  this  fact  that  on  the 
following  day  he  had  the  lecturer  permit  him  to  inhale  the  gas, 
and  whilst  under  its  influence  he  had  a  molar  tooth  extracted 
without  feeling  the  least  pain.  As  he  recovered  from  the  effects 
of  the  gas  his  first  words  were  :    "A  new  era  in  tooth-pulKng. " 

The  modern  practice  of  anaesthesia  dates  from  this  operation. 
Wells  appears  to  have  been  unaware  of  Sir  Humphrey  Davy's 
experiments.  He  found  the  peculiar  exhilarating  effects  de- 
scribed by  Davy  due  to  mixture  of  the  gas  with  atmospheric 
air  ;  for  when  precautions  had  been  taken  to  exclude  the  latter 
only  anaesthetic  effects  ensued  from  its  inhalation. 

Wells  gave  the- gas  to  more  than  a  dozen  of  his  patients  and 
with  complete  success.  Elated  with  this  good  fortune,  he  quickly 
obtained  permission  to  make  a  public  trial  of  it  at  the  Massa- 
chusetts General  Hospital.  Unfortunately,  the  bag  was  re- 
moved too  soon,  and  in  the  extraction  of  the  tooth  the  patient 
uttered  a  piercing  cry.  The  sceptical  audience  rudely  hooted  and 
hissed,  and  Wells  was  laughed  at  as  an  ignorant  pretender.  Now, 
Wells  was  a  modest  and  retiring  man  ;  he  felt  the  insult  deeply. 
Home  he  went,  mortified  and  disgusted,  yet  both  Wells  and 
Riggs  continued  in  their  practice  to  administer  the  gas,  but 
never  afterwards  resumed  their  experiments  in  public.  After 
a  few  years  Wells  fell  ill  from  vexation,  and  retired  from  his 
profession.      Subsequently,    he  visited    Europe    as  a  picture 


MODERN    ANAESTHESIA    AND    ANAESTHETICS.  29 

dealer,  then  returned  to  the  United  States,  became  more  and 
more  unsettled  in  his  mind,  and  finally  died  by  his  own  hand  in 
January,  1848.  For  a  lon^f  time  Wells'  just  claims  as  the  dis- 
coverer of  modern  anaesthesia  were  ignored  ;  indeed,  we  are 
only  now  beginning  to  do  justice  to  his  memory.  He,  at  least, 
never  attempted  to  make  a  secret  of  his  great  discovery  nor  to 
use  it  for  selfish  ends.  "On  making  the  discovery,"  says 
Wells,  "  I  was  so  much  elated  respecting  it  that  I  expended  my 
money  freely  and  devoted  my  whole  time  for  several  weeks  in 
order  to  present  it  to  those  who  were  best  qualified  to  investi- 
gate and  decide  upon  its  merits,  not  asking  or  expecting  any- 
thing for  my  services.  I  was  desirous  that  it  should  be  as  free 
as  the  air  we  breathe.  Judge,  therefore,  of  my  surprise,  after 
the  lapse  of  many  months,  when  I  was  informed  that  two  indi- 
viduals (Drs.  Jackson  and  Morton)  had  claimed  the  discovery 
and  made  the  application  for  a  patent  in  their  own  names." 

We  are  happy  to  state  that  a  chaste  and  handsome  monu- 
ment, with  a  statue  of  Wells,  has  been  erected  at  Hartford, 
Connecticut,  with  the  following  inscription  : 

"Horace  Wblls,  who  discovered  Anaesthesia, 
December  10th,  1844." 

Much  credit  is  due  to  Dr.  McManus  and  other  friends  of 
Wells  for  their  praiseworthy  eiForts  in  this  matter. 

I  am  glad  to  be  able  to  present  a  likeness  of  Horace  Wells, 
which,  no  doubt,  will  give  pleasure  to  thousands  who  now  profit 
by  his  valuable  discovery. 

The  use  of  nitrous  oxide  as  an  anaesthetic,  for  the  time  being, 
died  with  Wells,  and  the  discovery  was  again  in  danger  of  being 
lost.  Dr.  Colton's  praiseworthy  efiforts  to  reintroduce  the  gas 
were  vain  until  1863,  when  he  succeeded  in  inducing  a  few  prac- 
titioners to  try  it.  Its  use  spread  rapidly,  so  that  in  1867 — the 
j^ear  of  the  International  Exhibition  in  London — he  was  able  to 
visit  Paris  with  a  record  of  20,000  administrations  without  a 
single  accident.  He  met  with  very  little  encouragement  from  the 
Paris  faculty.  However,  in  the  spring  of  the  following  year,  his 
apparatus  was  brought  to  London  by  Dr.  Evans,  the  American 
dentist  resident  in  Paris,  who  administered  the  gas  before  the 


30  ARTIFICIAL    ANESTHESIA. 

Staff  of  the  Dental  Hospital,  and  thus  introduced  the  practice  in 
that  country.*  In  the  United  States  nitrous  oxide  was  well  re- 
ceived ;  and  in  1870  Dr.  Colton  published  in  a  medical  journal, 
and  afterwards  in  pamphlet  form,  the  result  of  the  physiological 
action  of  the  gas  in  its  practical  application  to  the  original  dis- 
coveries of  Davy,  Wells  and  others,  with  a  very  large  record  of 
the  successful  extraction  of  teeth. 

Unfortunately,  owing  to  the  comparative  feebleness  of  action 
of  nitrous  oxide  gas,  and  its  large  gaseous  bulk,  the  anaesthesia 


Plate  1. 


can  only  be  maintained  for  a  very  limited  period.  Hence  the 
employment  of  the  gas  has  hitherto  necessarily  been  restricted 
to  short  surgical  operations.  The  late  M.  Paul  Bert  partially 
succeeded  in  overcoming  this  objection  by  giving  instead  of  the 
pure  gas  a  mixture  with  oxygen  gas,  in  the  proportion  of  85 
volumes  of  nitrous  oxide  to  15  volumes  of  oxygen,  under  in- 
creased atmospheric  pressure  in  a  special  chamber  constructed 
for  this  purpose.  The  necessity  for  the  latter  part  of  this  pro- 
vision arises  from  the  fact  that  when  the  mixture  of  the  gases 

*  The  Journal  of  the  British  Dental  Association. 


DISCOVERY    OF    ETHER    AS    AN    ANESTHETIC.        31 

is  inhaled  alone  complete  anaesthesia  cannot  be  produced,  owinfr 
to  the  full  complement  of  nitrous  oxide  (45  volumes  to  100 
volumes  of  ox5'gen)  not  being  taken  into  the  lungs  during  res- 
piration. Under  the  increased  pressure  mentioned  sufficient 
nitrous  oxide  is  inhaled  to  produce  anaesthesia  and  sufficient 
oxygen  to  prevent  the  supervention  of  asphyxia.  Thus  more  or 
less  prolonged  anaesthesia  can  be  maintained.  After  many  ex- 
periments on  animals  this  method  has  been  tried  at  the  Paris 
Hospital  b}'  Peau  and  others,  but  with  partial  success.  It  is 
not  known  whether  it  is  emploj'ed  in  this  country.  The  requi- 
site apparatus  in  its  present  form  is  too  cumbrous  and  expensive 
for  general  use.  A  more  compact  apparatus  has  been  invented 
by  Dr.  Hewitt,  of  London,  and  with  it  the  nitrous  oxide  mix- 
ture can  be  kept  up  for  some  time,  and  thus  a  short  operation, 
or  the  extraction  of  a  number  of  teeth,  etc. ,  can  be  undertaken.^ 
A  full  account  will.be  given  under  nitrous  oxide. 


CHAPTER    11. 

The  Discovery  of  Special  Ansesthetics  and  the  Theory  of  their  Action 
— Local  Anaesthesia  and  Anaesthetics  —  Chloroform — The  True 
Value  of  Anaesthetics — Cocaine — Eucaiue  Hydrochlorate. 

Ether. 

"Pereira,"  in  his  famous  work,  then  as  now  a  familiar  text- 
book,! states,  "  The  vapor  of  ether  is  inhaled  ....  to  relieve 
the  effects  caused  by  the  accidental  inhalation  of  chlorine  gas." 
Again,  he  writes,  "  If  the  air  is  too  strongly  impregnated  with 
ether  stupefaction  ensues."  The  crowning  result,  however,  was 
obtained  in  1846  by  Dr.  Morton  in  the  Massachusetts  General 
Hospital,  when  it  was  demonstrated  successfully  that  the  in- 
halation of  ether  was  so  capable  of  deadening  the  sensibility  of 

"-■•  The  Journal  of  the  British  Dental  Association. 

t  Lectures  on  Materia  Medica  and  Therapeutics,  vol.  ii. 


32  ARTIFICIAL    ANESTHESIA. 

the  nervous  system  that  an  operation,  no  matter  how  painful, 
could  be  performed  without  suffering  to  the  patient.  In  the 
use  of  ether  as  an  anaesthetic  the  first  capital  operation — that 
is,  one  involving  one  of  the  larger  joints — was  performed  on 
October  17,  1846,  by  Dr.  Warren,  of  Boston. 

A  handsome  sum  of  money  should  have  been  given  both  Dr. 
Wells  and  Morton  for  their  devotion  to  the  cause  of  suffering 
humanity,  and  this  should  still  be  done  for  their  families.  It 
gives  me  pleasure  to  be  able  to  present  a  correct  likeness  (Plate 
2)  of  Dr.  Morton,  who,  though  he  erred,  should  long  ago  have 
been  forgiven  for  his  devotion  to  the  introduction  of  one  of  the 
most  valuable  anaesthetic  agents  given  to  the  profession  and  the 
public. 

Dr.  Jackson,  of  Boston,  claims  to  have  suggested  to  Dr. 
Morton  the  use  of  ether  as  an  anaesthetic  in  place  of  nitrous 
oxide.  With  regard  to  this,  it  may  be  stated  that  at  a  meet- 
ing of  the  Boston  Academy  of  Arts  and  Sciences,  where  the 
matter  was  being  discussed,  the  late  Professor  Louis  Agassiz 
said  to  Dr.  Jackson  :  "Did  you  make  even  one  little  experi- 
ment with  ether?"  and,  after  receiving  a  negative  reply,  added 
dryly;  "  It  would  have  been  better  if  you  had."  On  another 
occasion  Professor  Agassiz  said:  "  If  Dr.  Morton  had  killed 
his  first  patient  would  you  (Jackson)  have  accepted  the  blame, 
just  as  now  you  ask  for  the  honor?"  Dr.  Jackson  was  silent. 
The  names  of  Morton  and  Jackson  were,  however,  associated 
in  an  attempt  to  obtain  a  patent  for  the  process,  which  was 
frowned  upon  by  every  right-minded  physician  and  dentist. 

It  seems  that  among  other  after-claimants,  one,  an  estimable 
physician  of  (xeorgia.  Dr.  Crawford  W.  Long,  awakened  to  the 
fact,  only  so  late  as  1849  (three  years  after  anaesthetic  inhala- 
tion by  ether — 1846 — had  been  in  universal  practice),  that  it 
would  be  well  to  record  in  some  medical  journal  the  statement 
that  he  had  "used  ether  by  inhalation  in  surgical  operations  on 
several  occasions  "  (as  many  as  five  in  the  course  of  as  many 
years)  prior  to  1846.  He  accordingly,  in  December,  1849,  pub- 
lished "  an  account  of  the  first  use  of  ether  by  inhalation  as  an 
anaesthetic  in  surgical  operations."  This  communication,  tardy 
as  it  was,  Dr.   Long  very  properly  made  in  simple  justice  to 


DISCOVERY    OF    ETHER    AS    AN    ANESTHETIC.        33 


Plate  2. 


34  ARTIFICIAL    ANAESTHESIA. 

himself.  No  special  attention  was  paid  to  it  for  reasons  which 
will  soon  become  apparent.  He  seems,  indeed,  merely  to  have 
desired  to  place  himself  on  record  in  connection  with  this  sub- 
ject in  1849.  In  1877  this  forgotten  record  is  dragged  from  its 
obscurity  and  amplified  and  adorned  into  a  patent  of  discovery. 
The  interests  of  truth  will  be  best  served  b}''  referring  to  Dr. 
Long's  original  text.  One  quotation  will  establish  these  points. 
We  shall  be  brought  straightway  to  the  very  pith  of  the  case  by 
the  following  summary,  as  given  by  himself,  in  his  communica- 
tion of  1849,  already  referred  to:  "The  result  of  my  second 
experiment  in  etherization  was  such  as  led  me  to  believe  that 
the  anaesthetic  state  was  of  such  short  duration  that  ether  would 
only  be  applicable  in  cases  in  which  its  effects  could  be  kept  up 
by  constant  inhalation  during  the  time  of  the  performance  of 
the  operation.  Under  this  impression,  up  to  January,  1847,  I 
had  not  used  ether  in  but  one  case,  in  extracting  teeth,  and  thus 
deprived  myself  of  experimenting  in  the  only  class  of  cases 
which  are  of  frequent  occurrence  in  a  country  practice."  Now, 
in  the  first  place,  the  remarkable  admissions  contained  in  this 
sentence  would  be  valueless  if  any  subsequent  experiments  had 
taught  Dr.  Long  more  than  he  here  enunciates  ;  but  he  never, 
of  himself,  learned  more  than  this — for  he  distinctly  states  that 
he  "  was  under  the  impression"  embodied  in  this  quotation 
until  January,  1847,  three  months  after  the  announcement  of 
universal  and  practical  anaesthesia  in  1846. 

The  writer  still  holds  to  the  opinion  expressed  in  his  earlier 
editions,  that  the  safest  systemic  anaesthetic  in  prolonged  and 
capital  operations  is  ether,  and  in  this  opinion  he  is  upheld  by 
the  majority  of  surgeons,  by  a  committee  of  the  British  Medical 
Association,  the  British  Medical  Journal,  also  by  the  chief 
journals  of  the  United  States.     (See  Conclusion.) 

It  is  unfortunately  true  that  at  the  present  day  ether  deaths 
occur  more  frequently  from  carelessness  in  administration  and 
proportionately  larger  amount  used  than  in  years  gone  by. 

Sudden  deaths  were  extremely  rare,  but  are  now  more  fre- 
quent, owing,  we  think,  to,  first,  the  use  of  a  more  powerful 
ether,  and,  second,  to  carelessness  in  employment,  as  in  the  case 
of  a  recently  reported  death,  when  six  ounces  were  employed 


THE    TRUE    VALUE    OF    ANESTHETICS.  35 

for  a  non-capital  operation,  whicli  could  have  been  performed 
under  a  local  anaesthetic. 

One  reason  for  employing  so  large  a  quantity'  of  ether  is  the 
strong  desire  to  etherize  the  patient  as  rapidly  as  possible,  and 
neglect  to  use  the  minimum  quantity  to  keep  the  patient  pro- 
foundly anaesthetized. 

In  ether  it  is  almost  always  the  danger  from  interruption  of  the 
respiration,  and  secondarily  interference  with  the  heart's  action, 
hence  there  is  a  chance  for  the  use  of  artificial  respiration.  In 
such  cases  elevate  the  feet  and  lower  the  head  until  the  face 
flushes  and  shows  restoration  of  the  heart's  full  action. 

Chloroform. 

Discovery  of  Chloroform. 

This  valuable  anaesthetic  agent  was  first  discovered  in  an  im- 
pure state  as  "chloric  ether,"  in  1831,  by  Samuel  Guthrie,  of 
Sackett's  Harbor,  N.  Y.  Little  notice  was  taken  of  it  until 
Soubieran  and  Liebig  produced  it  in  a  pure  state  by  the  action 
of  chlorine  gas  upon  methyl  chloride,  a  year  after  the  discovery 
of  the  anaesthetic  qualities  of  ether  (1847). 

Professor  Simpson,  of  Edinburgh,  by  his  courage,  brought 
chloroform  into  use  upon  the  suggestion  of  Dr.  Waldie,  a 
chemist  of  Liverpool.  Simpson  found  by  experiment  that  a 
much  smaller  quantity  of  chloroform  than  of  ether  was  required 
to  produce  profound  anaesthesia,  the  former  being  more  prompt 
in  action  and  more  agreeable  to  the  patient  both  in  taste  and 
odor. 

Chloroform  had,  however,  a  great  drawback  in  general  use  as 
an  anaesthetic,  in  that  it  would  without  warning  cause  very  sud- 
den death  from  cardiac  syncope. 

The  True  Value  of  Anaesthetics. 

No  one  can  form,  even  at  the  present  day,  a  just  estimate  of 
the  true  value  of  the  various  anaesthetics  or  express  in  words 
their  wonderful  and  extended  application  to  the  relief  of  human 
suffering.  To  the  general  surgeon  it  gives  the  opportunity  of 
operating  in  grave  cases  of  disease  and  injury,  without  which 


36  ,  ARTIFICIAL    ANESTHESIA. 

the  death  of  the  patient  would  be  inevitable.  It  also  aiFords, 
by  the  immediate  relief  from  pain,  the  power  to  manipulate  the 
broken  or  injured  parts  with  facility,  and  thus  obtain  a  correct 
diagnosis  in  the  most  obscure  diseases  and  painful  accidents. 

To  the  obstetrician  and  gynaecologist  it  is  most  valuable  in 
assuaging  the  terrific  pain  of  labor,  and  makes  the  dreaded  in- 
strument a  blessing  in  disguise.  In  the  diagnosis  and  treatment 
of  abdominal  diseases  it  gives  precision  and  almost  marvellous 
results,  and  in  the  removal  of  large  masses  or  ovarian  tumors 
great  freedom  from  the  dreadful  effects  of  shock  to  the  nervous 
system.  For  the  ophthalmic  surgeon  the  local  anaesthetic  re- 
duces the  sensibility  of  the  eye  so  that  it  can  be  touched  and 
cut  with  impunity,  and  severe  and  dangerous  operations  can  be 
performed  upon  this  delicate  and  sensitive  organ  without  pain 
and  with  much  less  risk. 

Again,  in  the  removal  of  foreign  bodies  from  the  eye  or  ear, 
particularly  in  children,  by  the  use  of  the  local  anaesthetic  all 
spasm  is  relieved  and  the  act  is  accomplished  without  injury. 

The  profound  sleep  gives  a  most  favorable  opportunity  to  the 
aural  surgeon  to  perforate  the  membrane  tympani,  cut  the 
minute  tendon  of  the  tensor  tympani  muscle,  perforate  the 
mastoid  cells,  open  abscesses  and  remove  intramural  tumors 
from  the  brain. 

Theories  of  the  Manner  in  Which  Anaesthetics  Pro- 
duce Theii"  Effects. 

At  the  present  day  certain  theories  are  ventured  to  explain 
the  eflFects  of  general  anaesthetics  on  the  system  : 

1.  That  they  act  by  retarding  oxygenation  and  induce  a  true 
narcosis. 

2.  That  they  produce  actual  changes  in  the  blood,  thus  caus- 
ing secondary  inhibition  of  the  function  of  the  sensory  nerve 
cells. 

3.  That  they  merely  bring  about  cerebral  anaemia,  from  which 
condition  anaesthesia  results. 

4.  That  they  have  a  direct  action  upon  the  nervous  tissue 
itself. 

5.  There  is  no  true  similarity  between  the  phenomena  of  true 


COCAINE.  37 

anaesthesia  and  those  of  asphyxia  ;  the  conditions  are  not  iden- 
tical, and  when  asphyxia  takes  place,  which  occurs  with  all  anaes- 
thetics, it  is  a  complication  which  is  to  be  avoided,  especially 
with  nitrous  oxide,  ether  and  chloroform. 

In  regard  to  the  second  theory,  it  is  admitted  that  certain 
anaesthetics,  like  chloroform  and  ether,  produce  changes  in  the 
blood  and  in  the  heart,  and  if  carried  too  far  these  changes  will 
become  permanent ;  thej^  however,  are  neither  necessary  nor 
essential  to  the  production  of  true  anesthesia. 

It  is  somewhat  remarkable  that  the  fate  of  almost  all  the 
claimants  to  the  discovery  of  anaesthesia  was  so  tragical.  We 
have  already  referred  to  the  sad  end  of  Dr.  Wells.  Dr.  Charles 
T.  Jackson  died  at  Somerville,  Mass.,  after  a  seven  j^ears'  ill- 
ness, a  disappointed  man,  although  receiving  an  honorarium 
and  medal  from  the  G-overnment  of  France.  Morton,  having 
been  reduced  to  poverty  during  the  long  twelve  years  in  which 
he  endeavored  to  wring  from  Congress  and  the  courts  recog- 
nition of  his  rights,  died  suddenly  in  New  York  City,  in  1868, 
of  cerebral  congestion,  brought  on,  it  is  said,  by  reading  a 
work  attacking  his  claims.  How  much  more  fortunate  was 
Professor  Simpson,  of  Edinburgh,  whose  introduction  of  chlo- 
roform won  for  him  a  baronetcy,  the  highest  honors  of  his  pro- 
fession, a  statue  in  Edinburgh  and  a  memorial  bust  in  West- 
minster Abbey ! 

Long  was  the  happiest.  He  died,  comparatively  little  known, 
in  1878,  a  poor  man,  though  now  his  statue,  with  that  of  Ogle- 
thorpe, will  represent  Georgia  in  the  National  Gallery  at  the 
Capitol.  Owing  to  the  bitter  controversy  that  resulted  from 
the  claims  of  Wells,  Morton  and  Jackson  to  the  discovery  of 
ether  anaesthesia,  a  monument  was  erected  in  Boston  with  only 
the  following  inscription  : 

"To  commemorate  the  discovery  that  the  inhalation  of  ether 
causes  insensibility  to  pain.  First  proved  to  the  world  at  the 
Massachusetts  General  Hospital,  in  Boston.  October,  A.D. 
MDCCCXLYI." 

Cocaine. 

After  the  prolonged  use  of  the  systemic  anaesthetics,  ether, 
chloroform  and  nitrous  oxide,  from  1846  to  1896,  it  has  been 


38  ARTIFICIAL    ANAESTHESIA. 

found  that  with  the  free  use  of  chloroform  and  ether,  deaths 
would  follow  their  use  in  the  hands  of  even  the  most  expe- 
rienced, careful  and  conscientious  physicians  and  surgeons  all 
over  the  world.  The  deaths  from  the  third  agent,  nitrous  ox- 
ide, were  comparatively  few ;  but  owing  to  the  cost  and  the  me- 
chanical apparatus  required  for  its  use,  even  with  the  addition 
of  oxygen,  but  few  surgeons  would  employ  it  in  protracted 
operations.  It  was  still  a  desideratum  to  find  a  local  ancesthetic 
agent,  that  would  be  safe  and  could  be  employed  in  more  or  less 
extensive  operations.  In  1855,  Gaedeke  discovered  in  coca  an 
alkaloid  to  which  he  gave  the  name  "  erythroxyline."  This 
principle  was  first  thoroughly  studied  by  Dr.  Albert  Niemann, 
from  whom  it  received  the  name  "cocaine,"  and  he  found  it  to  be 
a  most  valuable  local  angesthetic.  The  first  to  use  it  extensively 
was  Dr.  Karl  Roller,  of  Vienna,  who  found  it  a  local  anaesthetic 
and  of  vital  importance  in  operations  upon  the  eye.  His  ex- 
periments and  observations  were  received  with  enthusiasm  all 
over  the  world,  but  especially  by  ophthalmic  surgeons. 

Like  every  other  new  anaesthetic,  it  was  applied  in  a  great 
variety  of  methods,  but  with  little  knowledge  of  its  true  physio- 
logal  action  and  in  too  strong  solutions.  We  made  a  series  of 
experiments  with  the  drug,  as  early  as  May,  1889,  in  the  labora- 
tory of  the  University  of  Pennsylvania,  to  determine  its  action, 
in  conjunction  with  Professor  Reichert. 

A  dog  weighing  8  kilo  was  injected  with  li  grains  of  Merk's 
hydrochlorate  of  cocaine.  Pulse  172,  temperature  38.9,  the 
amount  of  cocaine  being  at  the  rate  of  2  centigrammes  per  kilo. 
Without  going  into  detail,  there  were  jerking  movements  of  the 
muscles,  intoxication,  the  pupils  became  dilated,  balls  promi- 
nent and  hard  from  increased  intra-ocular  pressure.  In  the 
course  of  ten  minutes,  convulsions  supervened,  both  clonic  and 
tonic.  When  fully  under  the  influence  of  the  drug,  sight  and 
hearing  seemed  to  be  unimpaired  until  convulsions  set  in. 

In  another  experiment  in  a  dog,  weight  16^  kilo,  pulse  and 
temperature  were  the  same.  When  the  dose  of  the  cocaine  was 
doubled  and  the  injection  made  near  tlie  spine,  the  brain  be. 
came  evidently  very  much  affected  and  delirium  was  much  more 
decided,  with  great  excitement.     Respiration  very  much  more 


EUCAINE    HYDROCHLORATE.  39 

rapid,  with  panting  and  salivation.  Ears  thrown  back,  eyes 
protruding,  balls  hard,  pupils  dilated,  with  increased  heat  of 
body. 

The  fatal  dose  in  dogs  was  found  by  Dr.  Reichert  to  be  0.03 
gram  per  kilo.  Subcutaneous  injection  produced  local  anaes- 
thesia at  the  point  of  application.  When  taken  internally  it 
appeared  to  act  as  a  stimulant  and  in  large  doses  had  a  para- 
lyzing action  on  the  nerve  centres.  It  affects,  first,  the  cerebral 
hemisphere,  next  the  medulla  and  afterwards  the  spinal  cord. 

In  spite  of  these  and  other  careful  observations,  the  drug  was 
emploj^ed  in  large  quantities  and  in  very  improper  cases.  Grradu- 
ally,  as  cases  of  poisoning  took  place,  and  even  deaths  followed, 
alarm  was  taken,  and  many,  from  fear,  ceased  to  use  it. 

In  November,  1894,  Dr.  H.  V.  Wiirdemann  brought  to  the 
notice  of  the  American  medical  profession  his  experiments  and 
conclusions  obtained  by  following  out  Schleich's  method  and  the 
line  of  experiments  instituted  a  month  before  by  Schleich,  of 
Berlin,  relative  to  the  local  anaesthetic  properties  of  water 
associated  with  a  minute  quantity  of  cocaine,  morphia  and  sa- 
line water.  The  success  of  this  new  method  is  due  to  the  way 
in  which  the  injection  is  made,  as  care  is  taken  merely  to  affect 
the  tissues  to  be  involved  in  the  operation,  only  a  small  radius 
being  deadened  by  each  quantity  of  solution.  No  tissue,  either  of 
bone  or  muscle,  has  yet  shown  resistance  to  aqueous  anaesthesia 
if  rightly  followed. 

Cases  are  already  being  reported  from  parts  of  the  United 
States,  and  so  far  the  reports  seem  to  be  warmly  favorable  to 
the  adoption  of  the  new  method  in  all  surgery,  at  all  events,  in 
even  the  gravest  class  of  operations. 

Eueaine  Hydroclilurate. 

This  is  a  new  local  anaesthetic,  discovered  in  1896,  and  a  sub- 
stitute for  cocaine,  and  it  is  stated  by  a  number  of  good  au- 
thorities to  be  free  from  some  of  the  objections  to  cocaine. 
Like  cocaine,  eueaine  is  the  methylester  of  a  benzoj^lated  oxy- 
piperidin  carbonic  acid.  Its  constitution  is  represented  by  the 
formula : 


40 


ARTIFICIAL    ANESTHESIA. 


CfiH,  —  CO  —  0  —  n  -  COOCH 


CH, 
CH3C 


C.H, 

C-CH3 

CH, 


N.  C.H3 

The  hydrochlorate  of  eucaine,  which  is  to  replace  the  hydro- 
chlorate  of  cocaine ,  has  the  following  chemical  constitution  : 

CagH^^No^HCL. 

This  new  compound  differs  from  cocalin*  in  that  a  methyl 
group  is  substituted  in  it  for  a  hydrogen  atom  which  is  formed 
by  the  action  of  ammonia  upon  acetone. 


*  Cocalin  is  poisonous. 


PAET    SECOND. 

NITROGEN  MONOXIDE— NITROUS  OXIDE  GAS 

(NO-N2O), 


CHAPTER   III. 

Nitrous  Oxide  Gas — Mode  of  Preparation  and  Chenaical  Composition — 
Gasometer  and  Inhaling  from  it — Liquid  Mtrous  Oxide  and  In- 
halers— Ansesthesia  from  Nitrous  Oxide — Physiological  Action  of 
Nitrous  Oxide  Gas — Experiments  with  the  Gas — Additional  Facts 
in  Reference  to  the  Physiological  Action  of  Nitrous  Oxide. 

Nitrous    Oxide  Gas,  its    Mode  of  Pi'eparation  and 
Clieniical  Composition. 

As  nitrous  oxide  gas  was  the  first  agent  employed  under  the 
title  of  an  anaesthetic  we  have  placed  it  first  on  the  list  in  this 
edition.  It  has  powerful  claims  to  our  notice,  first,  that  so  few 
deaths  have  followed  its  careful  and  conscientious  use,  and,  sec- 
ond, it  is  the  most  extensively  employed  of  any  one  of  the  sys- 
temic angesthetics. 

Nitrogen  monoxide,  or  nitrous  oxide  gas  (NGr — N2O)  is  pre- 
pared from  the  nitrate  of  ammonia  (this  is  now  obtained  from 
the  waste  products  of  gas  works  by  the  action  of  nitric  acid) ; 
it  is  then  purified,  which  process  resolves  it  into  the  gas  and 
water,  thus  : 

NO3NH4  =  0  =  N2O  +  2  H2O. 

The  nitrate  of  ammonia  is  a  crystalline  salt,  but  for  conveni- 
ence of  introduction  into  the  retorts  should  be  in  granulated 
form,  which  can  be  obtained  of  the  manufacturing  chemist. 

4 


Plate  3  (Figs.  1,2,  3). 


Gasometer  aud  luhaler. 


GASOMETER    FOR    NITROUS    OXIDE    GAS. 


43 


Plate  4. 


Gasometer  for  Prepariiig^  Nitrous  Oxide  Gas. 

The  most  important  apparatus  to  be  furnished  is  a  convenient 
reservoir  or  gasometer  (this  can  be  made  bj'  any  intelligent  tin- 
smith, as  the  dental  depots  do  not  now  supply  them,  furnishing 
only  the  washing  bottles,  etc.),  an  illustration  of  which  is  seen 
at  Plate  3,  with  Nos.  1 ,  2  and  3  bottles.  These  can  be  obtained 
from  the  dental  depots.  Care  is  required  in  the  selection  of  the 
bottles  for  washing  and  purifying  the  gas.  Plate  4  represents 
the  best  form,  which  is  furnished  with  per- 
forated rubber  cork  and  glass  tubes  bent  at 
right  angles.  The  long  tube  which  dips  into 
the  bottle  is  pierced  with  small  holes  at  the 
bottom  nozzle  ;  this  agitates  the  gas,  and  so 
insures  its  more  thorough  washing.  In  puri- 
fying the  gas  some  employ  a  solution  of  sul- 
phate of  iron  in  bottle  No.  1 ,  and  pure  water 
in  the  other  two.  To  remove  chlorine  gas, 
which  is  sometimes  present,  and  can  be 
noticed  by  its  green  color  and  its  irritating 
action  upon  the  respiration,  a  small  stick  of 
caustic  potash  may  be  added  to  one  of  the 
bottles  containing  the  pure  water.  When 
no  chemical  agents  are  employed  in  the  puri- 
fication of  the  gas  it  should  be  well  washed 
through  fresh  water  and  allowed  to  stand  for 
some  hours  over  the  water  in  the  gasometer,  to  remove  any  im- 
purities that  may  have  passed  over.  Plate  o  represents  the 
gasometer  in  position.  The  holder  is  first  filled  with  water  to 
within  one  and  a  half  or  two  inches  of  the  top  ;  while  this  is 
being  done  take  ofi"  the  weights  and  open  all  the  spigots,  to 
allow  the  air  to  pass  out,  and  the  receiver  to  remain  in  position. 

The  long  pipe  of  bottle  No.  1  must  not  dip  under  the  water, 
for  the  tubing  thereby  becomes  choked  with  dense  vapor  and 
the  free  passage  of  air  is  interrupted. 

Into  wash-bottle  No.  2  place  about  four  ounces  of  sulphate  of 
iron,  and  add  sufficient  water  to  cover  the  end  of  the  dip-pipe, 
about  one  and  a  half  to  two  inches. 


44  Artificial  anesthesia. 

Into  wash-bottle  No.  3  it  is  unnecessary  to  place  anything  but 
fresh  water ;  yet  some,  fearing  the  chlorine,  add  a  stick  of 
caustic  potash.  Sufficient  water  should  be  employed  to  cause 
the  pipe,  which  dips  into  the  water,  to  sink  the  same  depth  as 
it  does  in  No.  2. 

When  bottles  are  prepared,  connect  them  with  a  piece  of  rub- 
ber tubing  and  to  the  spigot  of  the  gasometer.  If  they  are 
arranged  properly  a  current  of  air  blown  into  the  tube,  intended 
to  connect  with  the  retort,  will  cause  the  water  to  bubble  in  the 
wash-bottles  Nos.  2  and  3,  and  if  the  spigot  is  open  the  re- 
ceiver will  commence  to  ascend. 

Having  the  bottles  in  readiness,  and  properly  connected, 
place  the  quantity  of  nitrate  of  ammonia  which  will  be  required 
into  the  retort  (one  pound  of  granulated  salt  will  produce  about 
thirty  gallons  of  the  gas). 

There  is  a  stove-like  arrangement  heated  by  gas-burners,  with 
a  sand-bath  for  holding  and  heating  the  retort.  Connect  the 
retort  with  the  long  pipe  of  the  first  bottle  by  the  rubber  tub- 
ing, and  then  open  the  spigot  of  the  gasometer. 

The  heat  must  be  applied  graduall}'^,  first  to  melt  the  am- 
monia, about  226°  F. ,  and  then  to  cause  it  to  boil  and  give  ofi" 
gas  at  460°  F.  to  480°  F.  until  it  is  nearly  all  decomposed. 
When  the  gas  has  ceased  to  come  over  take  a  cloth  and  dis- 
connect the  retort  from  the  tubing  and  close  the  spigot  of  the 
gasometer. 

The  inhaling-tube  is  attached  to  the  spigot  at  the  top  of  the 
holder.  There  is  a  register  which  shows  the  number  of  gallons 
of  the  gas  in  the  receiver.  When  the  holder  is  filled,  close  the 
spigot  and  arrange  the  weights ;  it  is  then  ready  to  receive  the 
gas.  The  wash-bottles  are  placed  as  represented  in  Nos.  1,  2,  3, 
which  are  connected  one  with  the  other,  and  to  the  retort  and 
gasometer,  by  means  of  rubber  tubing.  The  first  bottle,  No.  1, 
is  placed  next  to  the  retort,  and  is  simply  used  to  catch  the  drip 
resulting  from  condensed  vapor. 

The  water  and  solutions  contained  in  the  wash-bottles  should 
be  changed  once  in  a  month.  When  nitrous  oxide  gas  is  thus 
obtained  it  is  colorless,  almost  inodorous  and  of  a  sweetish  taste. 
The  chemical  composition  is  as  follows:   Nitrate  of  ammonia 


IRON    RETORTS    FOR    MAKING   NITROGEN    GAS.        45 

resolves  itself  into  nitrous  oxide  gas  and  water;  thus  NO3NH4 
=  N2O  +  2  ll-iO.  The  heat  necessary-  to  cause  active  evolution 
of  gas  is  stated  to  be  460°  F. ,  and  this  heat  should  be  kept  up, 
else  a  portion  of  the  salt  will  sublime.  The  heat  should  never 
be  allowed  to  rise  above  482°  F, ,  as  the  nitric  oxide  is  apt  to  be 
given  off  in  the  form  of  an  orange-colored  vapor.  In  infinitesi- 
mal explosions,  nitric  oxide  is  a  dangerous  impurity,  as  it  can- 
not be  breathed  unless  very  much  diluted,  and  tends  to  suspend 
respiration  and  produce  spasm  of  the  muscles  of  inspiration. 
To  determine  the  proper  temperature  a  thermometer  is  prepared 
which  can  be  passed  into  the  cork  and  into  the  retort,  so  that  no 
risk  from  superheating  need  be  incurred  by  the  introduction  of 
poisonous  materials  into  the  gas. 

After  the  gas  is  made  it  should  stand  over  water  for  a  few 
hours,  not  longer,  else  endosmotic  action  will  take  place  and 
weaken  the  gas  before  using.  This  will  do  little  toward  insur- 
ing absolute  purity  of  the  gas  ;  neither  will  washing  it  through 
the  solutions  of  iron  and  potash  purif\'  it  perfectly.  Should 
there  be  chlorine  present  (which  is  the  poisonous  element)  in 
the  nitrate  of  ammonia  no  amount  of  washing  through  solutions 
will  obliterate  it.  The  ammonia  should  alwaj's  be  tested  before 
using ;  this  is  done  by  dissolving  about  a  teaspoonful  in  half  a 
tumbler  of  distilled  water  and  applying  a  few  crystals  of  nitrate 
of  silver.  If  the  ammonia  be  pure  the  solution  will  remain 
perfectly  clear  ;  but  should  chlorine  be  present  it  will  show  a 
clouded  appearance  and  impure  ammonia,  which  must  be  dis- 
carded altogether. 

Iron  Retorts  for  Making'  Protoxide  of  Xitrogen  Gas. 

Nitrous  oxide  for  dental  operations  has  come  into  general 
use,  and  dentists  making  their  own  nitrous  oxide  must  have 
doubtless  met  with  great  difficulties  in  consequence  of  the 
breaking  of  the  glass  retorts.  To  obviate-  this  inconvenience, 
the  idea  has  been  suggested  to  use  iron  retorts.  One  can  be 
made  of  rolled  iron.  14  inches  long  by  6  inches  wide,  outside 
measure,  of  a  quarter  of  an  ijich  thick,  the  joints  being  brazed 
together  and  perfectly  air-tight.  The  bottom  of  the  bottle  is 
convex  outside  and  concave  inside,  and  the  top  opening  is  one 


46  ARTIFICIAL    ANESTHESIA. 

inch  wide,  with  a  threaded  screw  inside  the  mouth  of  the  bottle. 
To  this  is  attached  a  tube  two  feet  long  with  a  threaded  screw 
to  enable  the  unscrewing  of  the  tube  in  order  to  put  the  nitrate 
of  ammonia  into  the  bottle.  The  iron  tube  is  bent  at  a  curve 
just  above  the  mouth  of  the  bottle,  and  is  two  feet  long,  and 
the  other  end  of  the  tube  being  on  a  level  with  the  moutli  of 
the  bottle,  the  bottle  can  be  either  suspended  or  placed  over  a 
gas-burner  or  on  a  fire  and  the  receiver  remain  in  position. 
The  iron  retort  must  be  lined  with  porcelain.  All  gas  must  be 
purified  before  being  employed,  by  the  same  method  as  above 
directed. 

Inhalers. 

Next  to  pure  gas,  a  perfect  inhaler  is  most  essential  to  the 
successful  administration  of  nitrous  oxide. 

Thomas'  Nitrous  Oxide  Inhaler. 

The  Thomas  Inhaler,  Plate  5,  used  with  gasometer,  is  turned 
from  a  piece  of  vulcanized  rubber,  eight  inches  long  by  three 
inches  square,  leaving  the  mouth-piece   one  inch  and  a  half 

Plate  5. 


ENTRANCE 

\IA0UL  JUiPi  f  ""^  MOUTH 

PIECE 


across.  The  diameter  of  the  opening  is  a  little  more  than  one- 
half  an  inch  with  stOp-cock  in  the  centre,  in  which  is  the  inhal- 
ing valve.  This  is  constructed  of  a  simple  piece  of  rubber  dam 
secured  by  a  pin  to  a  stopple,  in  which  are  three  oblong  aper- 
tures which  have  the  inhaling  valve  at  the  extremity  of  the  in- 
haler. The  aperture,  being  of  sufficient  size,  is  made  so  as  not 
to  obstruct  the  free   passage  of  the  nitrous  oxide  gas.     The 


INHALER    FOR    NITROUS    OXIDE.  47 

valves  are  three-quarters  of  an  inch  in  diameter,  and  the  stopple 
is  of  vulcanized  rubber. 

It  must  liave  a  tube  large  enough  to  admit  the  gas  so  freely 
that  the  most  nervous,  as  well  as  patients  with  weak  lungs,  can 
inhale  through  it  without  exertion,  and  it  must  be  perfectl}' 
air-tight. 

Some  inhalers  are  so  constructed  that  it  is  only  by  using  great 
effort,  that  patients  can  supply  air  to  the  lungs  to  the  amount  of 
their  natural  capacity,  causing  them  to  struggle  or  go  into  the 
anaesthetic  sleep  with  such  feelings  of  suffocation  and  depres- 
sion, that  they  will  drift  into  dreams  of  the  most  frightful  char- 
acter, and  become  almost  unmanageable  in  their  excitement. 

Nitrous  Oxide  Inhaler. 

This  inhaler*  is  the  simplest,  cleanest,  most  convenient, 
most  effective  ever  used  for  the  administration  of  nitrous  oxide. 
It  is  almost  entirely  automatic  in  its  action,  and  requires  the 
use  of  but  one  hand,  the  inlet  valve  being  opened  by  a  slight 
pressure  of  the  thumb,  so  that  the  gas  can  be  turned  on  without 
the  patient's  knowledge.  Upon  the  removal  of  the  pressure, 
the  valve  closes  automatically  and  shuts  off  the  gas. 

The  sectional  view  shows  the  internal  construction.  An  open- 
ing, B,  underneath  the  body  of  the  inhaler  admits  the  gas 
through  a  similar  opening,  A,  in  a  sliding  tube,  GG,  fitting  in- 
side of  and  projecting  beyond  the  rear  portion  of  the  main  body. 
The  projecting  portion  is  perforated  for  the  admission  of  air, 
and  its  outer  end  is  closed  by  a  cap.  At  the  inner  end  of  the 
sliding  tube  is  a  coil  spring,  E  E,  abutting  against  a  shoulder 
in  the  body  of  the  inhaler.  This  spring  holds  the  sliding  tube 
in  the  position  shown  in  the  cuts,  closing  the  inlet,  B,  when 
the  gas  is  not  being  used.  Pressure  on  the  cap  compresses  the 
spring,  closes  the  perforations  for  the  admission  of  air,  and 
brings  the  opening  A  over  B,  affording  a  free  flow  of  gas  to  the 
mouth-piece  through  the  inhaling  valve.  The  sliding  tube  is 
prevented  from  rotating  by  the  screw-pin,  D,  which  works  in  a 
slot,   C.     The   inhaling   and   exhaling  valves — the   former  in- 

*  The  S.  S.  White  Co. 


Plate  6. 


ternal,  the  latter  external— consist 
of  two  thin  disks  of  mica,  F  F, 
which  are  inclosed  in  circular  open 
cages.  The  inhaling  valve  is  open- 
ed in  respiration  by  being  drawn 
against  the  front  of  the  cage,  the 
exhaling  valve  being  closed  by  the 
pressure   of  the   outside    air.     In 


expiration  both  disks  are  thrown 
against  the  further  ends  of  the  cages, 
opening  the  exhaling  and  closing  the 
inhaling. 

The  entire  inhaler,  except  the 
mouth-piece  and  the  two  valve-disks, 
is  of  metal,  smoothly  finished,  the 
outside  polished  and  nickel-plated. 
It  is  readily  taken  apart  for  clean- 
ing.    The  illustrations  are  half-size. 


Flexible  Face-Pieee  tor  Inhalers. 

Plate  7. 


50  ARTIFICIAL    ANESTHESIA. 

In  this  form  of  face-piece  the  oval  shape  is  maintained  by  the 
peculiar  metal  fittings,  as  shown  in  detail.  It  can  be  applied  to 
the  JNo.  1  or  No.  3  inhaler. 

The  inhalers  which  cover  the  entire  face  are  sometimes  objec- 
tionable to  delicate  patients.  It  must  be  remembered  that  the 
color  of  the  blood,  as  shown  through  the  mucous  membrane  of 
the  lips  is  one  of  the  principal  guides  to  the  condition  of  the  pa- 
tient during  the  inhalation  of  gas,  and  if  they  are  covered  too 
closely  from  view  by  the  hood  or  otherwise,  we  have  lost  that 
means  of  diagnosis.  In  instances  of  hare-lip,  or  where,  from 
swelling  or  other  causes,  the  muscles  of  the  jaw  become  so  con- 
tracted as  to  render  it  impossible  to  pass  the  mouth-piece  be- 
tween the  teeth,  a  rubber  covering  is  recommended. 

Inflatable  Face -Piece  for  Inhaler. 

The  inflatable  face-piece  consists  of  a  soft  rubber  hood  with 
an  inflatable  edge-cushion  attached  to  a  metal  frame,  which  is 
screwed  into  the  inhaler.  The  frame,  which  preserves  the 
shape  of  the  hood,  may  be  readily  detached  for  cleansing  by  un- 
screwing the  nut  which  holds  it  to  the  neck  of  the  inhaler.  The 
cushion  is  inflated  through  the  little  tube.  The  best  adaptation 
to  the  face  is  obtained  when  it  is  only  partially  distended. 

The  inflatable  face-piece*  consists  of  a  soft  rubber  hood  with 
an  inflatable  edge-cushion  attached  to  a  metal  frame,  which  is 
screwed  into  the  inhaler.  This  frame,  which  preserves  the 
shape  of  the  hood,  may  be  readily  detached  for  cleansing  by  un- 
screwing the  nut  which  holds  it  to  the  neck  of  the  inhaler.  The 
cushion  is  inflated  through  the  little  tube.  The  best  adaptation 
to  the  face  is  obtained  when  it  is  only  partially  distended. 

This  is  an  improvement  on  a  face-piece  which  has  been  in  use 
in  England  for  several  years.  In  adapting  it  to  the  No.  3  in- 
haler we  have  found  it  desirable  to  place  the  exhaling-valve  on 
the  frame  of  the  face-piece. 

*  The  S.  S.  White  Co. 


Inflatable  Fa<ie-Piece. 

Plate  8. 


52  ARTIFICIAL    ANAESTHESIA.. 

An  Improved  Nitrous  Oxide  Gasometer.* 

An  Apparatus  for  Administratiou. 

The  complete  apparatus  consists  of  a  cast-iron  stand  (on  rol- 
lers) for  holding  the  c^^linder  and  gasometer,  brass  or  copper 
reservoir  or  water-holder,  with  bell  or  gas  receiver,  guide-rod 
for  same,  one  foot  one-quarter  inch  rubber  tubing.  No.  3  in- 
haler with  inflatable  face-piece  and  four  feet  covered  tubing, 
metal  connection  for  tubing,  wood  holder  for  inhaler,  two  Rus- 
sia iron  jackets  (one  each  for  large  and  small  gas  cylinders), 
wheel  kej'  and  yoke. 

The  gasometer  is  very  simple  in  construction,  and  handsome 
in  appearance.  Instead  of  an  unsightly  gallows  frame  for  guid- 
ing the  bell,  it  is  supplied  with  a  nickle-plated  guide-rod,  before 
referred  to.  This  guide-rod  is  marked  to  show  the  number  of 
gallons  of  gas  in  the  bell.  The  bell  has  a  capacity  of  eight  gallons. 
It  is  "  balanced,"  as  it  leaves  our  hands,  by  means  of  a  "float," 
so  that  it  will  sink  with  the  slightest  inhalation  of  gas.  The 
"float"  is  an  annular  air-tight  chamber  slid  into  the  bottom  of 
the  bell,  with  its  inner  surface  surmounted  with  two  screw-caps 
containing  ordinary  gun-shot.  Should  it  be  desirable  to  change 
the  "  balance"  of  the  bell  the  "float"  can  be  readily  removed 
and  the  quantity  of  shot  added  to  or  decreased,  as  may  be  re- 
quisite. In  this  event  remove  the  bell  from  the  guide-rod,  un- 
screw the  nut  which  holds  the  "  float "  in  position  and  take  out 
the  "float." 

Directions. — Screw  the  guide-rod  I  into  the  bottom-plate 
inside  of  the  reservoir  E,  first  removing  the  cork  which  is  in- 
serted to  exclude  dirt  or  chips  from  the  packing  material,  and 
using  say  an  excavator  handle  in  the  hole  at  the  top  of  the  rod 
to  tighten  it ;  attach  the  wood  inhaler  holder  H.  Put  the  bell 
F  in  position,  making  sure  that  the  guide-rod  enters  the  tube 
extending  through  the  centre.  Open  the  valve  G  (it  is  a  piston 
valve  and  is  to  be  merelj^  drawn  out),  and  with  pitcher  or  dip- 
per pour  water  into  the  tank,  filling  it  to  the  bead  at  tho  base 
of  the  flaring  rim. 

Close  the  valve  (r,  attach  the  inhaler  tubing  to  the  valve  by 

■•••  I  am  indebted  to  the  S.  S.  Wbite  Co.  for  this  improved  gasometer. 


IMPROVED    NITROUS    OXIDE    GASOMETER. 


53 


means  of  the  metal  connection,  and  set  the  gas  cyHnder,  with 

Plate  9. 


its  jacket  adjusted,  in  the  stand.     Observe  that  large  cylinders 
are  set  in  the  socket  A  at  the  base  of  the  stand,  small  ones  on 


54  ARTIFICIAL    ANESTHESIA. 

the  ledge  or  flange  C  at  one  side  of  the  reversible  clamp  B. 
After  clamping  the  cylinder  firmly  by  means  of  the  screw  D, 
and  adjusting  the  yoke,  connect  it  by  the  rubber  tubing  to  the 
pipe  at  the  bottom  of  the  reservoir — opposite  the  valve  G,  but 
not  seen  in  the  cut — and  the  gasometer  is  ready  for  the  admis- 
sion of  the  gas. 

The  valve  G  is  simply  a  cork  plug,  vs^hich  of  course  has  to  be 
pulled  out  during  the  administration  of  gas.  It  is  placed  there 
to  prevent  the  escape  of  gas  through  the  valves  of  the  inhaler 
when  not  in  use, 

Liquid  Nitrous  Oxide. 

Under  a  pressure  of  fifty  atmospheres,  at  45°  F.,  the  nitrous 
oxide  gas  is  condensed  by  a  pump  into  a  clear,  transparent 
liquid,  while  the  cylinders  are  kept  in  ice. 

This  form  has  been  found  so  convenient  that  with  many  phj"- 
sicians  and  dentists  it  has  taken  the  place  of  the  gaseous  form. 
One  of  the  best  forms  of  valve  is  the  Johnson  Gras-Valve 
(Plate  10). 

Description. — The  seat  A  (shown  by  V-shaped  dotted  line) 
is  made  of  soft  alloy,  which  easily  receives  the  impress  of  the 
plug,  and  of  course  the  impress  must  exactly  fit  the  point  which 
makes  it.  It  can  be  easily  operated  by  a  child  with  a  small 
wrench. 

The  plug  is  made  in  two  pieces,  B  and  C,  united  by  a  ball- 
and-socket  joint,  so  that  the  moment  the  point  touches  the  seat 
it  is  prevented  from  revolving,  and  the  rotary  motion  takes 
place  at  the  ball  joint,  thus  preventing  any  wear  or  grinding  on 
the  seat. 

The  cock,  D,  unscrews  from  the  seat,  exposing  the  latter  for 
inspection  or  repair. 

Projecting  from  the  end  of  the  plug  down  into  the  gas  pas- 
sage is  a  long  and  slightly-tapering  point ;  this  nearly  closes  oif 
the  opening,  even  after  the  jjlug  is  raised  from  its  seat,  and 
there  is  no  annoying  rush  of  gas,  even  when  the  plug  is  raised 
several  turns. 

The  valve  is  handsomely  finished  and  nickel-plated  exter- 
nally, and  discharges  through  the  yoke  in  a   manner  readily 


IMPROVED    NITROUS    OXIDE    GASOMETER. 


55 


understood  from  the  cut.  It  is  operated  by  a  small  hand-wheel 
or  wheel-ke}',  which  is  provided  with  a  set-screw  to  secure  it  in 
position  and  thus  avoid  all  danger  of  its  dropping  off,  which 
might  otherwise  occur  at  the  most  critical  moment  in  an  opera- 
tion. 

Plate  10. 


By  the  use  of  a  prop  one  has  a  fair  opportunity  to  perform 
the  operation  to  his  entire  satisfaction  ;  but,  without  it,  there 
is  danger  of  the  patient  bruising  and  possibly  breaking  the  front 
teeth,  by  biting  so  hard  upon  the  mouth-piece,  when  recovering 
from  the  effects  of  the  gas,  before  the  mouth  can  be  opened 
sufficiently  wide  to  admit  of  the  extraction  of  a  tooth,  or  any 
operation  upon  the  mouth. 


56  ARTIFICIAL    ANiESTHESIA. 

Nitrous  oxide  must  always  be  pure  to  insure  success,  though 
some  have  recommended  it  after  it  has  stood  over  water  one  or 
two  weeks,  and  even  a  month  ;  but  it  is  impracticable.  This  is 
obviated  in  the  liquid  gas. 

A  Seamless  Steel  Gas  Cylinder. 

This  is  a  great  improvement  over  the  old  iron  cylinder.  These 
cylinders  are  made  without  weld  or  seam,  of  a  single  piece  of 
steel  of  a  special  formula,  stipulated  by  the  S.  S.White  Co.  under 
the  advice  of  engineers  who  make  steel  and  its  adaptations  a 
specialty,  its  composition  being  so  proportioned  as  to  insure  the 
metal  against  hardening  to  brittleness. 

The  inspection  of  the  metal  and  all  the  processes  of  its  manu- 
facture have  been  under  our  direction. 

The  walls  of  these  cylinders  are  almost  absolutely  uniform  in 
thickness,  thereby  securing  the  least  possible  weight  compatible 
with  strength  adequate  to  meet  the  pressure  required. 

The  cj^inders  measure  4  inches  outside  diameter  by  17  inches 
long,  clear  of  valve  and  neck,  or  2U  inches  long  over  cap  and 
all,  have  a  capacity  for  250  gallons  of  liquified  nitrous  oxide 
gas,  or  for  75  gallons  of  compressed  oxygen,  and  have  an 
average  weight  of  16  pounds  without  the  cap,  and  16|  pounds 
with  cap  and  valve  complete. 

This  cylinder  is  lighter  in  weight,  stronger  and  of  greater 
storage  capacity  in  proportion  to  the  weight  of  metal. 

These  cylinders  will  be  found  bearing  our  test  of  3000  pounds 
per  square  inch  plainly  stamped  on  the  bottom. 

They  have  carried  the  tests  on  a  number  of  these  to  ascertain 
the  strain  required  to  rupture  them  by  hydrostatic  pressure, 
which  has  demonstrated  the  fact  that  it  requires  from  7000  to 
8500  pounds  per  square  inch. 

In  these  tests  it  was  found  that  the  metal  possessed  a  high 
degree  of  ductility,  as  the  cj^linders  swelled  so  as  to  increase 
their  diameter  very  perceptibly  to  the  eye  long  before  bursting 
pressure  was  reached. 

In  employing  liquid  gas  allow  a  certain  amount  of  space  above 
the  liquid  for  expansion  of  the  gas  when  subjected  to  varying 
temperatures.     The  S.   S.   White  Dental  Manufacturing  Co. 


A    SEAMLESS    STEEL    GAS    CYLINDER. 


57 


Plate  11. 


has  found  that  in  a  seamless  steel  gas  cyhnder  containing  512 
gallons  of  gas,  submitted  to  a  temperature  of  95°  Fahrenheit, 
the  pressure  indicated  on  the  gauge 
was  3200  pounds,  and  that  in  the 
same  c.vlinder,  when  the  quantity 
of  gas  was  reduced  to  452  gallons, 
and  subjected  to  the  same  tem- 
perature, the  pressure  was  reduced 
to  1725  pounds  to  the  square  inch. 

They,  for  this  reason,  refuse  to 
put  more  than  from  450  to  452 
gallons  in  500-gallon  C3dinders. 
These  500-gallon  cylinders  are  de- 
signed for  those  who  use  large 
quantities  of  nitrous  oxide. 

Directions.  —  Use  a  single 
leather  washer  on  the  coupling- 
joint  of  the  yoke  attachment. 

The  valve  is  the  only  proper  and 
sufficient  means  of  retaining  the 
gas ;  neither  the  bag  nor  the  in- 
halers will  prevent  its  escape  if  the 
valve  is  left  open. 

After  detaching  the  bag  from 
the  cylinder,  test  the  valve  to  be 
sure  that  it  is  closed.  This  may  be 
readily  ascertained  in  a  very  simple 
way,  as  follows :  Take  a  little 
saliva  from  the  mouth  on  the  fin- 
ger, and  gently  pass  it  over  the 
outlet  of  the  valve,  so  as  to  form 
a  film  over  the  opening.  If,  be- 
cause of  imperfect  closure  of  the  f"  i,  Cap  exposed.  Fig.  2, 
valve,  there  is  any  escape  of  gas.  Cap  covering  the  cylinder, 
the  film  will  be  forced  outward  in 

the  form  of  a  bubble.  A  slight  turn  more  of  the  hand-wheel 
and  the  film  may  remain  stationary  or  show  a  tendency  to  sink 
inward  from  the  pressure  of  the  external  air,  proving  that  there 

5 


58  ARTIFICIAL    ANAESTHESIA. 

is  no  escape  of  gas.  Should  any  difficulty  be  experienced,  the 
cylinder  should  be  returned  at  once. 

Cylinders  contahmig  gas  should  never  he  exposed  to  heat,  as 
that  greatly  increases  the  pressure. 

Always  close  the  valve  after  emptying  the  cylinder. 

The  usual  quantity  of  gas  given  to  a  patient  is  from  3  to  5 
gallons. 

If  it  is  desirable  to  keep  the  patient  under  the  influence  of 
the  anassthetic  for  a  prolonged  period  (as  in  a  surgical  opera- 
tion) the  operator  has  under  his  control  500  gallons  of  gas  by 
merely  turning  the  key  seen  in  the  cut  at  the  right. 

On  the  bell  of  the  gasometer  there  is  a  scale,  graduated  in 
gallons  and  fractions  of  a  gallon,  so  that  the  operator  can  readily 
see  how  much  gas  he  has  administered. 

Another  valuable  feature  of  this  gasometer  is  a  peculiar 
water-check  or  valve,  so  arranged  that  though  the  gas  flows 
freely  on  the  slightest  inspiration  at  the  inhaler  it  is  instantly 
and  automatically  shut  off  by  the  water  when  the  patient  stops 
breathing.  This  prevents  all  waste  of  gas ;  it  also  saves  the 
surgeon's  or  dentist's  time  at  the  most  critical  moment,  as  he 
has  only,  after  having  administered  the  gas,  to  lay  aside  the 
inhaler  and  proceed  at  once  to  operate  without  the  necessity 
of  shutting  any  stop-cock.  The  stand  is  so  constructed  that  a 
small  (10-gallon)  cylinder  can  be  used  while  the  larger  cylinder 
is  being  refilled. 

We  also  call  attention  to  the  fact  that  there  is  no  liability  to 
loss  of  gas  from  leakage  caused  by  the  operator's  leaving  the 
valve  of  the  cylinder  open,  for,  if  there  is  such  escape  from  the 
cylinder,  the  bell  of  the  gasometer  will  rise,  and  the  operator 
having  his  attention  called  to  the  waste  will  be  enabled  to  cor- 
rect the  difficulty  at  once. 

The  gas  can  be  kept  for  any  length  of  time,  and  is  constantly 
on  hand  and  always  of  the  best  quality. 

The  diagram  (Plate  12)  represents  a  sectional  view  of  a 
nickel-plated  gasometer. 

Two  metallic  cylinders,  AA,  are  arranged  concentrically  to 
form  a  water-holding  space  between  their  approximating  walls, 
while  a  third  cylinder,  having  a  cover  with  a  guide-rod,  C,  at- 


A    SEAMLESS    STEEL    GAS    CYLINDER. 


59 


tached  to  the  cover,  is  lowered  into  the  water-space  as  a  seal 
between  the  cylinders,  and  to  form  a  gas-chamber,  D,  at  the 
top.  The  inner  cylinder  is  provided  with  a  central  tubular 
cavity,  closed  at  the  bottom,  to  receive  the  guide-rod  of  the 
cover. 

It  is  obvious  that  the  chamber,  D,  will  be  enlarged  or  dimin- 


Plate  12. 


:=AA 


ished  according  to  the  volume  and  pressure  of  the  gas,  which 
rises  to  the  chamber  from  the  iron  cylinder,  E,  beneath  the 
gasometer,  when  the  valve  is  opened,  through  the  connecting 
tube  and  pipe,  FF.  The  gas  is  conducted  to  the  inhaler  from 
the  chamber,  D,  through  a  closed  cylindrical  water-vessel,  Gr, 
attached  to  the  wall  of  the  inner  cj'linder,  and  provided  with 
an  inlet  pipe,  H,  and  an  outlet  pipe,  I,  which  latter  is  carried 
to  the  outside  at  right  angles  to  the  gasometer,  and  receives  the 


60  ARTIFICIAL    ANJ5STHESIA. 

tubing  which  conducts  the  gas  to  the  inhaler.  This  closed  ves- 
sel, G,  is  also  provided  with  a  water  outlet  to  overflow,  J,  and 
the  whole  forms  a  very  simple  and  effective  trap  for  shutting  off 
the  gas  when  not  inhaled.  In  operation  it  is  only  necessary, 
before  the  cover  is  placed  in  position,  to  pour  into  the  water- 
space  between  the  cylinders  enough  water  to  nearly  fill  it,  and 
into  the  inlet  pipe,  H,  sufficient  water  to  overflow  the  outlet,  J, 
or  the  trap,  the  rubber  stopper,  K,  of  the  latter  being  removed 
for  that  purpose  and  replaced  when  the  overflow  has  ceased. 
Then  insert  the  cover  and  open  the  valve  of  the  iron  cylinder 
beneath. 

The  vacuum  in  the  vessel,  Gr,  produced  by  each  inhalation  is 
immediately  filled  up  by  the  gas  passing  through  the  water  and 
upward  to  the  outlet,  I.  The  instant  that  inhalation  ceases 
the  gas  is  arrested  and  confined  at  the  water-level  in  the  trap. 

Directions  for  Setting  Up  and  Using  the  Gasometer. 
— Unpack  carefully  the  two  boxes,  removing  all  the  hay  from 
the  smaller  one  before  trying  to  lift  the  gasometer  from  the  box. 
Lift  the  top  (bell)  of  the  gasometer  clear  of  the  water-tank  and 
set  the  plated  tank  on  the  top  of  the  iron  stand,  placing  it  so 
that  the  tube  underneath,  to  which  the  inhaler  tubing  is  to  be 
attached,  shall  come  exactly  opposite  the  small  hole  provided  in 
the  iron  base.  With  a  cup  or  dipper  fill  the  annular  space  in 
the  body  of  the  gasometer  (tank)  with  water  to  within  three 
inches  of  the  top  and  pour  about  a  pint  of  water  into  the  trap 
through  the  large  tube  seen  in  the  top  of  the  gasometer. 

To  Adjust  for  a  bOO- Gallon  Cylinder. — Secure  the  wider  of 
the  two  iron  rings  in  position  near  one  of  the  feet  of  the  stand 
by  means  of  the  screw  provided  for  the  purpose.  Keeping  the 
large  cylinder  horizontal  (the  stop-cock  end  may  rest  on  the 
floor),  place  the  bottom  of  the  cylinder  in  the  ring,  being  care- 
ful, of  course,  not  to  drop  the  cylinder,  and  observing  that  the 
delivery  opening  of  the  stop-cock  is  to  the  right. 

Now  slide  the  other  iron  ring  over  the  top  of  the  cylinder  and 
elevate  this  end,  at  the  same  time  adjusting  the  ring  so  that 
the  projection  on  its  side  will  enter  the  slot  provided  for  it 
under  the  centre  of  the  gasometer,  and  allow  the  pin  to  be  put 
in  place,  securing  it  in  position.     Tighten  the  set-screws  in  the 


A    SEAMLESS    STEEL    GAS    CYLINDER.      •  61 

upper  ring  against  the  cylinder,  using  the  key  sent  with  the 
apparatus,  so  that  it  cannot  turn  around  when  the  stop-cock  is 
opened  or  closed. 

To  Adjust  for  a  100- GaJJon  Cylinder. — It  is  only  necessary  to 
slide  the  cylinder  into  its  place  horizontally  through  the  opening  in 
the  side  of  the  iron  base,  keeping  the  delivery  opening  of  the  stop- 
cock toward  the  right,  fastening  it  in  position  by  means  of  the 
long  set  screws  which  project  through  the  side  of  the  iron  base. 

In  either  case  (whether  a  100-  or  a  500-gallon  cylinder)  screw 
the  yoke,  which  will  be  found  attached  to  a  rubber  tube  under 
the  gasometer,  to  its  place  on  the  stop-cock  of  the  cylinder, 
being  sure  that  there  is  a  leather  washer  properly  placed  on  the 
union  tube.  A  leather  washer  will  be  found  attached  to  every 
C3"linder.  This  mnst  he  attended  to  every  time  a  new  cylinder  is 
placed  in  position. 

Draw  the  small  rubber  stopper  from  the  end  of  the  tube 
under  the  gasometer  and  allow  all  the  water  that  will  to  flow 
from  the  tube  into  a  basin  or  pail,  and  then  replace  the  cork 
tight. 

Now  (and  not  before)  return  the  bell  to  its  place,  being  care- 
ful to  enter  the  central  rod  and  the  graduated  scale  into  their 
respective  guides.  After  the  slight  spluttering  around  the 
edge  of  the  bell  is  over,  if  the  foregoing  directions  have  been 
followed  properly,  the  bell  will  remain  balanced,  and  a  very 
slight  (a  few  ounces  only)  pressure  of  the  hand  on  its  top  will 
cause  it  to  settle  gradually. 

Before  letting  gas  into  the  gasometer,  force  the  bell  entirely 
down,  to  remove  all  air.  It  is  well  to  let  in  a  few  gallons  of  gas 
and  to  force  this  out  also,  so  as  to  expel  the  last  traces  of  air 
from  the  gasometer.  Now  attach  the  inhaler  and  tubing  to  the 
gasometer  by  sliding  the  connection  on  the  end  of  the  tubing 
firmly  to  its  place  through  the  hole  in  the  side  of  the  iron  base ; 
then  with  the  nickel-plated  cap  cover  the  opening  through 
which  the  100-gallon  cylinder  goes  to  its  place,  and  the  appa- 
ratus is  complete. 

Directions  for  Using. — To  let  gas  into  the  gasometer,  open 
the  stop-cock  on  top  of  the  cyHnder  with  the  key.  The  stop- 
cock of  both  the  100-  and  500-gallon  cylinders  can  be  reached 


62 


ARTIFICIAL    ANESTHESIA. 


through  the  hole  in  the  centre  of  the  nickel-plated  cap  men- 
tioned above. 

The  numbers  on  the  graduated  scale  indicate  gallons  and 
enable  one  to  determine  the  amount  of  gas  used  by  each  pa- 
tient; thus,  if  10  appears  just  at  the  top  of  the  water-tank 
when   beginning  to  administer  the  gas,  and  after  the  admin- 

Plate  13. 


istration  6  stands  at  the  same  place,  four  gallons  of  gas  have 
been  used. 

We  would  suggest  that  in  beginning  the  use  of  this  apparatus 
a  record  be  kept  of  the  number  of  gallons  of  gas  used  by  each 
patient. 


WALL-BRACKET    FOR    GAS    CYLINDERS.  6B 

Wlien  liquid  gas  is  used,  five  gallons  is  sufficient  for  ordinary- 
dental  operations. 

When  the  ordinary  gas  as  made  by  dentists  is  used,  an  aver- 
age quantity  of  about  eight  gallons  is  necessary. 

After  administering  the  gas  it  is  unnecessary  to  stop  to  shut 
the  stop-cock  of  the  inhaler  before  commencing  the  operation, 
as  the  trap  will  shut  off  the  gas  automatically.  It  is  well,  how- 
ever, to  shut  the  stop-cock  immediately  upon  completing  the 
operation,  as  otherwise  the  tubing  will  fill  with  air,  which  will 
interfere  with  the  next  administration. 

A  large  hook  will  be  found  under  the  gasometer,  upon  which 
the  coiled  inhaler  tubing  may  be  hung,  when  it  is  desired  to  set 
the  apparatus  out  of  the  way. 

Cautions. — 1st.  Do  not  blow  into  the  inhaler  tubing  when  the 
inhaler  is  not  in  place,  as  it  will  derange  the  water-trap. 

2d.  If,  for  any  reason,  it  is  necessary  to  remove  the  bell  from 
its  place,  first  disconnect  the  union  from  the  cylinder,  so  as  to 
admit  air  to  the  gasometer,  and  then  raise  the  bell  gently  and 
slowl3\ 

Wall-Bracket  for  Gas  Cylinders.— (Plate  13.) 

This  is  an  excellent  device  for  use  in  offices  where  the  gas  is 
administered  frequently.  The  bracket  may  be  attached  to  the 
window  casing  or  other  woodwork.  As  the  wall  bracket  has  a 
yoke  attachment,  it  can  be  arranged  to  a  stand  on  the  floor  of 
the  office.  For  greater  convenience  a  small  cylinder  is  made, 
containing  bag,  inhaler  and  tubing,  in  a  metal  case  for  carrying 
by  the  surgeon  to  the  patient's  house. 

Surgeon's  Case. 

The  complete  apparatus  consists  of  an  iron  cylinder  contain- 
ing at  least  100  gallons  (usually  more)  of  nitrous  oxide,  lique- 
fied, to  which  is  attached  the  necessary  tubing,  with  gas  bag 
and  inhaler;  the  whole  inclosed  in  a  stout  leather-covered  case 
lined  with  velvet.  The  small  stop-cock  inserted  in  the  tubing 
between  the  bag  and  cylinder  enables  the  operator,  after  having 
filled  the  bag,  to  shut  off  the  gas  and  disconnect  the  bag  froni 


64 


ARTIFICIAL    ANAESTHESIA. 


the  cylinder,  if  desired  for  use  where  it  is  not  convenient  to 
carry  the  cylinder. 

In  manufacturing  the  surgeon's  case  particular  attention  has 
been  given  to  each  and  every  part,  so  as  to  insure  not  only  a 

Plate  14. 


complete  but  the  very  best  apparatus  of  its  kind.  These  are 
made  for  100-gallon  cylinders  only. 

The  case  is  made  of  well-seasoned  wood,  lined  with  velvet  and 
covered  with  leather,  and  the  mountings  are  nickel-plated.  A 
stout  cast-steel  ring,  neatly  japanned,  with  a  heavy  set-screw, 
clamps  the  cylinder. 

The  No.  1  case  has  a  4j-gallon  bag ;  the  No.  2  case  a  7-gal- 
lon  bag. 


surgeon's  upright  case. 


65 


Siirg^eoii's  Uprif^ht  Case. 

In  this  form  of  case  the  cylinder  stands  on  end,  which  is 
reckoned  by  some  operators  an  advantage  in  permitting  a  free 
flow  of  gas.     The  small  stop-cock  inserted  in  the  tubing  between 


Plate  15. 


the  bag  and  cylinder  enables  the  operator,  after  having  filled 
the  bag,  to  shut  off  the  gas  and  disconnect  the  bag  from  the 
cj^linder,  if  desired  for  use  where  it  is  not  convenient  to  carry 
the  cylinder. 
These  cases  are  only  made  for  100-gallon  cylinders. 

The  Proper  Method  of  Administermg^  Nitrons 
Oxide  Gas  as  an  Anaesthetic. 

The  most  important  matter  is  to  have  an  intelligent  assistant. 
It  is  never  safe  to  be  without  one.     Artificial  teeth  must  be  re- 


66  ARTIFICIAL    ANESTHESIA. 

moved,  and  if  the  patient  is  very  old  or  feeble,  or  there  is  a 
fatty  heart  or  diseased  lungs,  the  reclining  posture  is  the  safest. 
The  ordinary  position  is  the  sitting-up  or  half-reclining. 

The  operator  stands  on  one  side,  and  carefully  introduces  be- 
tween the  teeth  a  prop  of  wood  or  hard  rubber,  to  which  is 
attached  a  string.  The  patient's  dress,  if  a  female,  is  opened, 
and  the  cravat  is  loosened  if  a  male.  Everything  should  be 
done  without  undue  haste.  Nor  should  any  noise  or  loud  talk- 
ing be  allowed  in  the  operating-room.  The  inhaler  is  then 
placed  between  the  lips  and  teeth  of  the  individual  to  be  oper- 
ated upon,  and  the  nose  is  dasped  between  the  two  fingers  if 
there  is  no  face-piece  employed.  The  gas  is  now  turned  on,  and 
the  patient  is  directed  to  let  the  mind  dwell  on  some  pleasant 
object — occasionally  we  have  found  a  few  notes  from  a  musical- 
box  very  agreeable  when  the  patient  is  reviving.  If  there  is 
a  face-piece  to  the  inhaler,  it  is  to  be  gently  applied,  with  just 
sufficient  pressure  to  prevent  the  escape  of  the  gas,  and  the  pa- 
tient directed  to  make  slow  and  deep  breathing.  Keep  the  bag 
full  of  gas.  Let  the  assistant  watch  carefully  the  pulse  and  res- 
piration, opening  the  ingress  of  the  gas  during  inspiration  and 
closing  it  during  expiration. 

Usually  it  requires  from  twenty  to  twenty-five  seconds  to  fill 
the  lungs  with  the  gas ;  then  appears  pallor  of  the  skin,  with 
slight  darkening  of  the  nails  and  finger-tips,  yet  consciousness 
may  be  still  present,  and  the  inhalation  may  have  to  be  con- 
tinued from  five  to  ten  seconds  longer. 

For  emergencies,  the  operator  or  his  assistant  should  have 
within  reach  a  napkin  to  draw  out  the  tongue,  an  artery  forceps 
to  hold  it  if  necessary,  nitrite  of  amyl  in  case  of  extreme  pale- 
ness, but  not  if  much  flushed.  Above  all,  to  be  able  to  invert 
the  patient  so  that  the  blood  will  reach  the  anaemic  brain,  or 
place  him  on  the  floor,  opening  the  windows  and  performing 
artificial  respiration.  Stertor,  with  slight  jactitation,  are  signs 
that  the  patient  is  ready  for  operation,  and  is  caused  by  vibra- 
tion of  the  aryteno-epiglottic  folds.  This  comes  on  after  at  least 
a  minute,  and  must  not  be  confounded  with  the  "  snoring  "  of 
patients  who  suff'er  from  enlarged  tonsils  or  post-nasal  adenoid 
growths. 


PROPER    METHOD    OF    ADMINISTERING    GAS.  67 

The  evidence  of  returning  consciousness  is  the  normal  color 
in  the  face  and  lips,  with  a  cry  or  movement  of  the  hands. 
For  long-continued  operations  in  dental  surgery,  or  any  surgical 
operation,  a  combination  of  nitrous  oxide   and  ether  is  one  of 
the  best. 

The  following  is  the  improved  apparatus  of  Clover  for  nitrous 
oxide  and  ether.     This  is  seen  in  Plate  1 5. 

It  consists  of  a  tripod  supporting  a  east-iron  bottle  containing 
fifty  gallons  of  nitrous  oxide  gas,  the  bottle  being  gripped  firmly 
by  a  screw.  The  supply  is  regulated  by  the  administrator's 
foot,  which  is  placed  upon  the  foot-piece,  K.  '  This  is  provided 
with  teeth  which  bite  into  the  boot,  and  enable  the  adminis- 
trator, by  turning  his  foot  to  the  left,  to  open  the  outlet  of 
the  gas.  R  is  the  connection  between  the  bottle  and  the  Cattlin 
bag,  Gr. 

The  small  metallic  receiver  can  be  filled  with  warm  water  to 
obviate  freezing  of  the  ether  in  cold  weather.  The  India-rubber 
tube  will  be  seen  to  fix  on  a  stop-cock  in  front  of  the  ether 
receiver,  which  latter  is  suspended  by  a  hook  from  the  adminis- 
trator's coat.  When  only  gas  is  to  be  given,  the  stop-cock  on 
the  ether  vessel  is  put  at  right  angles  to  the  long  axis  of  the 
bag;  when  ether  is  to  be  used,  this  stop-cock  is  turned  into  the 
long  axis  of  the  bag.  The  stop-cock  in  front  of  the  ether-re- 
ceiver is  more  conveniently  placed  just  above  where  the  tube  is 
seen  to  end.  The  Cattlin  bag  is  so  arranged  as  to  allow  of  pure 
nitrous  oxide,  pure  ether,  or  a  mixture  of  these  two  substances 
to  be  administered.  The  supply  is  regulated  directly  by  the 
stop-cocks  above-mentioned,  but  more  immediately  by  an  ar- 
rangement represented,  though  not  very  clearly,  at  Re.  It 
consists  of  a  semi-circle  of  plated  metal,  upon  which  are 
engraved  at  opposite  ends  the  letters  Gr  and  E.  An  indicating 
rod  plays  upon  this  by  simply  shifting  the  indicator,  so  that  it 
revolves  free  of  the  semi-disc,  and  the  air  is  inspired.  When 
the  indicator  points  to  Gr,  nitrous  oxide  passes  into  the  face- 
piece,  and  as  the  indicator  travels  toward  F,  ether  vapor  is 
permitted  to  mix  with  the  gas  until  arriving  fully  at  E,  when 
pure  ether  is  inhaled.  The  cushioned  face-piece  is  used  by 
Clover,  and  is  supplied  with  a  simple  expiratory  valve. 


68 


ARTIFICIAL    ANESTHESIA. 


Should  a  supplemental  bag  be  used,  the  face-piece  must  be 
provided  with  an  aperture  to  which  this  accessory  can  be 
adjusted.  The  stop-cock  in  this  arrangement  is  kept  shut  until 
the  residual  air  of  the  lungs  is  presumably  exhausted,  when  it 
is  opened,  the  finger  placed  upon  the  expiratory  valve,   and 

Plate  16. 


the  patient  allowed  to  breathe  backwards  and  forwards  into 
the  bag. 

When  desirable,  it  is  a  simple  matter  to  convert  the  Cattlin 
bag  into  a  supplemental  bag  (for  oxygen  gas)  by  placing  a 
finger  upon  the  expiratory  valve,  and  so  causing  the  patient  to 
expire  back  into  the  Cattlin,  as  well  as  inspire  from  it. 

Where  a  gasometer  is  employed,  as  in  the  case  of  Dr.  Thomas, 
of  Philadelphia,  and  others,  a  modification  of  the  above  appa- 
ratus may  be  used. 


-PHYSICAL    PROPERTIES    OF    NITROGEN    MONOXIDE.       69 

A  long  tube  screws  on  to  the  efferent  pipe  of  tlie  gasometer, 
conveying  the  gas  to  a  bag  of  two  or  three  gallons'  capacity. 
This  may  be  connected  directly  with  a  face-piece,  or  convej'ed 
to  it  by  another  length  of  tubing,  and,  by  using  a  three-way 
cock,  it  is  easy  to  combine  this  apparatus  in  gear  with  Clover's 
smaller  ether  inhaler. 

Attachments  for  gas  cylinders  have  been  devised  in  this 
country  by  Lewis,  of  Buffalo,  and  Dr.  A.  M.  Long,  in  which 
the  gas  is  made  to  combine  with  the  vapor  of  other  anaesthetics, 
such  as  chloroform,  ether,  etc.  The  latter  has  a  combining- 
chamber,  through  which  the  gas  passes  from  the  cjdinder  on  its 
way  to  the  gasometer.  There  is  a  receptacle  for  the  liquid 
agent.  When  a  handle  below  is  turned  half-way  round,  the 
two  separate  tubes  meet,  and  drop  by  drop  the  liquid  passes 
into  the  combining-chamber. 

The  Pliysical  Properties  and  Physiological  Action 
of  Nitrogen  3Ionoxicle — Xitrous  Oxide  (Xo — X2O). 

Nitrous  oxide  gas,  when  pure,  should  be  free  from  color  or 
odor.  It  has  a  sweetish  taste.  It  is  an  active  supporter  of 
combustion.  A  taper  will  burn  in  it,  but  the  decomposition  of 
the  nitrous  oxide  is  due  to  the  high  heat,  for  at  the  ordinary 
temperature  of  the  body  it  is  not  decomposed.  Seeds  will  not 
germinate  in  it,  and  animals  live  longer  in  this  atmosphere 
than  in  one  of  nitrogen.  During  nitrous  oxide  narcosis,  the 
amount  of  carbonic  acid  exhaled  from  the  lungs  is  only  two- 
thirds  of  that  eliminated  before  the  inhalation.  It  has,  how- 
ever, the  one  quality  of  producing  a  sense  of  exhilaration, 
freedom  from  pain  and  true  anaesthesia  which  no  other  mixture 
of  nitrogen^  carbonic  acid,  air  or  hydrogen  can  produce,  prov- 
ing that  the  theory  of  asphyxia  is  only,  in  part,  the  true  one, 
the  circulation  having  been  found  very  differently  affected  by 
mechanical  or  chemical  agents  than  by  nitrous  oxide. 

Nitrous  oxide  gas  should  be  kept  in  a  liquid  state  or  made 
freshly,  for  it  is  a  well-known  and  recognized  fact  that  if  kept 
over  water  it  absorbs  nearly  its  own  bulk.  We  have  before 
expressed  our  opinion  that  when  the  gas  is  administered  in  its 
pure  state,  it  enters  the  air-cells  of  the  lungs  and  circulates  in 


70  ARTIFICIAL    ANESTHESIA. 

the  blood.  In  confirmation  of  our  own  views,  Dr.  C.  A.  Mac- 
Munn  ("The  Spectroscope  in  Medicine,"  London,  1880,  pp. 
73-75)  finds  that  when  an  animal  is  killed  by  nitrous  oxide  the 
arterial  blood  gives  only  spectrum  lines  by  reducing  haemo- 
globin, while  after  chloroform  or  even  ether  those  of  oxyhaemo- 
globin  are  very  apparent.     See  Da  Costa  experiments. 

The  marked  resemblance  between  the  effects  produced  by 
nitrous  oxide  and  those  resulting  from  asphyxia  were  observed 
by  the  earlier  experimenters  with  ether,  and  a  few  eminent 
physiologists  at  once  expressed  the  opinion,  and  still  hold  to  it, 
that  the  physiological  action  was  the  same  ;  but  at  the  present 
day  this  is  not  generally  entertained. 

The  following  is  a  summary  of  the  various  facts  bearing  on 
the  subject,  i.e.,  in  regard  to  the  physiological  action  of  nitrous 
oxide. 

It  would  seem  that  this  accumulated  evidence  is  not  sufiicient 
to  show  that  the  anaesthesia  produced  by  the  inhalation  of 
nitrous  oxide  is  not  simply  asphyxia.  Nitrous  oxide  gas  pro- 
duces in  man,  even  when  mixed  with  air,  a  feeling  of  exhilara- 
tion and  stimulation  which  would  indicate  that  it  is  not  merely 
a  passive  agent,  but  acts  also  as  a  narcotic.  The  discolored 
appearance  of  the  patient  while  under  its  influence  is,  to  a  great 
•extent,  due  to  the  accumulation  of  carbonic  acid  in  the  blood, 
ivhile  the  addition  of  a  few  inspirations  of  air  or  oxygen  will 
prevent  it. 

Nitrogen,  when  inhaled,  acts  upon  the  animal  economy  solely 
by  the  exclusion  of  oxygen.  When  nitrogen  or  hydrogen  is 
taken  into  the  lungs,  it  gives  rise  to  no  feeling  of  exhilaration, 
but  sometimes  to  malaise  and  a  sense  of  impending  suffoca- 
tion. 

After  death,  which  has  been  very  rare  from  nitrous  oxide, 
the  following  is  the  condition  of  the  lungs :  these  organs  are 
found  neither  voluminous  nor  collapsed  ;  of  a  light  pink  or 
Tose  color,  and  generally  with  one  or  more  small  circular, 
well-defined  ecchymotic  spots,  usually  on  their  posterior  sur- 
face. 

The  lungs  are  moderately  crepitant,  and  the  blood,  which 
•escapes  from  an  incision,  is  more  or  less  full  of  gas  bubbles. 


PHYSICAL    PROPERTIES    OF    NITROGEN    MONOXIDE.       71 

These  bubbles  will  be  found  in  the  bronchial  ramifications  mixed 
with  mucus,  and  in  one  or  two  instances  the  trachea  was  filled 
with  rusty,  frothy  fluid,  so  common  after  drowning. 

The  local  effects  of  nitrous  oxide  were  found  to  be  like  those 
produced  by  carbonic  acid. 

They  both  act  upon  the  blood-corpuscles  so  as  to  darken 
them.  The  lividity  upon  the  lips  and  the  darkening  of  the 
mucous  surfaces,  seen  every  day  in  the  operating-room  after 
administration  of  nitrous  oxide,  are  the  result  of  this  action. 
The  inhalation  of  nitrous  oxide  is  followed  by  an  increased 
exhalation  of  carbonic  acid  until  a  certain  point  is  reached, 
when  it  diminishes. 

The  conditions  which  are  obtained  after  the  inhalation  of 
nitrous  oxide  and  other  anaesthetics  are,  first,  to  stimulate,  then 
narcotize,  then  destroy  nervous  action  by  (a)  an  interference, 
more  or  less  marked,  with  the  oxj^genation  of  the  blood  and 
the  consequent  imperfect  accomplishment  of  certain  chemico- 
vital  processes  ;  by  {h)  a  retention  in  the  blood  of  a  portion  of 
the  usual  pulmonary  exhalations,  carbonic  acid,  etc.,  these  sec- 
ondary conditions  always  finally  co-operating  with  the  specific 
action  of  the  anaesthetic  in  the  production  of  narcosis,  the 
arrest  of  innervation,  and  in  the  suspension  of  every  functional 
movement  for  a  time,  with  a  rapid  return  to  health.  Latterly 
it  has  been  proven,  both  by  experiment  and  observation,  that 
the  theory  which  for  a  time  prevailed  in  the  United  States, 
"that  nitrous  oxide  acts  upon  the  blood  as  an  oxj^genating 
agent,"  is  incorrect.  No  experimental  proof  has  yet  been  fur- 
nished that  nitrous  oxide  is  decomposed  in  the  blood  or  forms 
chemical  combinations  with  it.  It  enters  the  blood  as  nitrous 
oxide,  and  as  such  is  eliminated.  It  will  naturally  be  inferred 
from  this  statement  that  the  presence  of  nitrous  oxide  in  the 
blood  is  not  indicated  by  the  appearance  (except  change  of 
color),  as  before  stated.  This  was  first  very  conclusively  proven 
by  the  late  Dr.  J.  H.  McQuillen,  Professor  of  Physiology  m 
the  Philadelphia  Dental  College. 

The  late  Dr.  F.  R.  Thomas,  of  this  city,  placed  his  whole 
apparatus,  with  a  large  supply  of  recently-made  pure  nitrous 
oxide  gas,  at  the  disposal  of  Dr.   McQuillen  and  the  writer, 


72  ARTIFICIAL    ANAESTHESIA. 

and  we  repeated  the  experiments  in  confirmation  of  the  facts  : 
that  the  gas  had  no  positive  poisonous  qualities  ;  second,  that 
the  blood-corpuscles  were  very  slightly  flattened  and  com- 
pressed, but  returned  to  their  normal  appearance  when  air  was 
introduced. 

First  Series. — The  experiments  were  as  follows  :  In  our 
examinations  of  the  blood  of  man  and  animals,  when  ether  and 
chloroform  were  brought  in  direct  contact  with  it  out  of  the 
body,  under  a  fifth  objective,  the  discharge  of  the  nuclei  and  the 
disintegration  of  the  corpuscles  invariably  occurred,  and  in  the 
frog  left  a  result  similar  to  that  which  is  presented  in  the 
accompanying  drawing  (Plate  16)  from  one  of  my  specimens, 
wherein  it  will  be  observed  that  the  field  is  occupied  by  the 
nuclei,  debris  of  disintegrated  globuline  and  corpuscles,  in 
which  the  changes  of  form,  size  and  other  characteristics  are 
most  striking. 

Second  Series. — On  placing,  however,  two  glass  slides  con- 
taining frog's  blood  over  watch-crystals,  one  holding  chloroform 
and  the  other  ether,  and  covering  them  with  glass  finger-bowls 
for  half  an  hour,  thus  exposing  one  to  an  atmosphere  of  ether 
and  the  other  of  chloroform,  we  found,  on  removing  the  bowls, 
and  permitting  the  bloody  sides  of  the  slides  to  remain  down- 
ward until  all  ether  and  chloroform  had  evaporated,  that  no  dis- 
integration or  marked  change  in  the  form  of  the  corpuscles  was 
observable  under  the  microscope,  on  comparing  them  with  the 
blood  of  a  frog  unaifected  by  an  anaesthetic.  This  forcibly 
demonstrates  the  difi'erence  between  exposure  of  the  blood  to 
direct  contact  to  the  vapor  of  chloroform  or  ether  even  out  of 
the  body. 

Third  Series. — Over  and  over  again,  in  the  presence  of  a 
number  of  gentlemen,  we  have  placed  frogs  under  the  influence 
of  nitrous  oxide  and  examined  their  blood-corpuscles  immedi- 
ately after  without  finding  any  disintegration  or  change  in  the 
form  of  the  corpuscle,  except  in  the  haemoglobin. 

It  seems  to  us  that  the  above  experiments  demonstrate  that 
we  are  not  warranted  in  denying  that  this  agent  acts  directly 
upon  the  nerve-centres.  All  the  phenomena,  indeed,  attendant 
upon  their  administration,  the  gradual  exaltation  of  the  cere- 


PHYSICAL    PROPERTIES    OF    NITROGEN    MONOXIDE. 


73 


Plate  17. 


bral  functions,  followed  b}'  the  progressive  impairment  and  tem- 
porar\'  suspension  of  the  special  senses,  the  loss  of  co-ordination 
on  the  part  of  the  cerebellum,  and,  when  the  agent  is  pushed 
too  far,  the  arrest  of  respiration  and  circulation  through  the 
decided  impression  made  upon  the  medulla  oblongata  seems  to 
favor  this  h\'pothesis,  in  contradistinction  to  the  theor}''  that 
anaesthesia  is  due  to  suspension 
of  oxygenation.  In  1887  there 
was  another  series  of 

Experiments  with  Nitrous 
Oxide,  by  Dr.  Turnbull  and  the 
late  Drs.  McQuillen  and  J.  D. 
Thomas,  December. — A  large- 
sized  frog  was  placed  under  a 
glass  jar  holding  five  quarts  of 
pure  nitrous  oxide,  and  kept 
there  sixteen  minutes.  With 
the  exception  of  some  change 
in  the  color  of  the  skin,  there 
was  no  apparent  impression 
made  the  first  five  minutes,  as 
he  jumped  about  when  the  jar 

was  moved  in  the  pneumatic  trough.  After  that  he  assumed 
the  position  of  sitting  on  the  bottom  of  the  jar,  and  maintained 
it  until  removed  from  the  jar,  when  he  was  found  in  a  semi- 
torpid  state,  with  the  eyes  wide  open.  On  touching  them 
gently,  the  lids  closed  and  then  opened  immediately,  and  the 
leg  retracted  on  pricking.  Two  minutes  after  removal  from  the 
jar,  lie  moved  slowly  about  the  floor,  and  ten  minutes  later 
hopped  from  a  table  on  to  the  floor. 

After  remaining  out  for  thirty-five  minutes,  he  was  again 
placed  under  the  jar  in  a  fresh  supply  of  gas,  and  kept  there 
for  thirty  minutes ;  on  being  removed,  he  presented  the  same 
semi-torpid  condition,  and  recovered  from  it  in  two  minutes. 
In  twenty  minutes  he  was  a  third  time  placed  in  fresh  nitrous 
oxide,  and  remained  there  fifteen  minutes,  with  the  same  result 
as  in  the  previous  trials,  the  confinement  for  one  hour,  in  all, 
to  the  influence  of  nitrous  oxide  not  having  made  any  marked 

6 


Frog's  blood  placed  upon  the 
slide,  and  cliloroform  brought 
in  direct  contact  with  it. 


74  ARTIFICIAL    ANESTHESIA. 

impression  on  liim.  Examined  under  one-fifth  objective,  and 
B,  eye-piece,  the  blood-corpuscles  presented  no  disintegrative 
discharge  of  nuclei  or  change  of  form. 

A  small-sized  rabbit  was  kept  under  the  influence  of  nitrous 
oxide  for  two  minutes,  and  in  one  minute  after  was  completely 
restored  to  consciousness.  He  was  then  kept  under  the  gas  for 
five  minutes  consecutively,  and  recovered  in  one  and  a  half  min- 
utes. After  this,  for  twenty  minutes,  off  and  on,  the  animal 
was  under  the  influence  of  the  gas.  In  three  minutes  after 
removal  from  it,  he  was  running  around  the  room  as  though 
nothing  had  occurred.  The  blood,  examined  under  the  micro- 
scope, gave  no  evidence  of  disintegration  of  the  blood-corpuscles. 
"There  is  reason  to  conclude  that  the  inhalation  of  either 
nitrous  oxide  or  nitrogen  causes  an  accumulation  of  carbonic 
acid  in  the  blood.  To  produce  oxidation  of  the  brain  there  must 
be  (1)  a  free  current  of  blood  through  the  capillaries  of  the 
brain;  (2)  the  blood  must  be  duly  aerated  or  oxygenized;  (3) 
the  blood  must  be  unmixed  with  any  material  which  prevents 
or  impedes  the  giving  up  of  oxj^gen  from  the  blood  to  tissues." 

The  Spectroscope  and  its  Relations  to  Anaesthetics. 

It  has  been  stated  that  "through  the  agency  of  the  spectro- 
scope has  been  supplied  the  missing  hnk  to  our  chain  of  reason- 
ing. The  shadowy  field  of  theories  has  been  cleared  up^  the  laws 
governing  the  relations  of  anaesthetics  in  contact  with  the  blood 
current  have  been  ascertai)ied^  and  rational  progress  has  been 
made  to  insure  safe  anaesthetics.  I  have  abiding  faith  in  the 
progress  of  chemical  science  that  it  will  finally  point  out  an 
agent  from  the  almost  inexhaustible  materials  at  its  command 
that  will  satisfy  all  surgical  requirements — an  anaesthetic  that, 
while  it  will  annihilate  temporarily  all  sensation,  will  leave  con- 
sciousness and  vitality  intact. " 

Now,  let  us  logically  apply  all  these  ascertained  facts  to  our 
case  in  hand  in  order  to  learn  how  this  gas  produces  its  effect 
upon  the  economy. 

From  our  experiments  we  have  seen  that  dogs,  when  per- 
mitted to  inhale  oxygen  at  the  highest  stage  of  dyspnoea,  be- 
come rapidly  as  well  as  ever  after  the  inhalation  of  nitrous  oxide 


EXPERIMENTS    WITH    THE    SPECTROSCOPE.  75 

gas.     A  certain  effect  upon  the  blood  has  taken  place,  often  un- 
important and  transient. 

Experiments  with  the  Spectroscope. 

These  experiments  in  the  course  of  spectroscopic  studies  of 
the  blood  by  the  action  of  reagents  were  made  by  the  writer  and 
the  late  Prof.  J.  G.  Richardson  of  the  University  of  Pennsylva- 
nia, Dr.  William  M.  Hodges  of  New  York,  and  the  author's 
son^  Dr.  C.  S.  Turnbull  of  Philadelphia. 

Pigeon,  under  the  anaesthetic  influence  of  nitrous  oxide  gas. 
Respiration,  38  ;  pulse — unable  to  count — from  182  to  210. 
Was  rendered  insensible  in  twenty  seconds,  and  had  quite  re- 
covered in  one  minute. 

Rabbit. — Blood  identical  with  human  blood  under  micro- 
spectroscope  previous  to  nitrous  oxide  administration.  Respi- 
ration, 138':  pulse,  160.  Was  affected  in  forty  seconds  and 
completely  insensible  in  two  minutes.  A.11  heart  action  ceased 
in  one  minute  and  forty-five  seconds.  There  was  no  change  in 
the  blood  under  the  spectrum  after  death  ;  little  or  no  change 
in  the  brain,  perhaps  slightly  anaemic  ;  heart's  color  natural. 

Dr.  L.  Turnbull  and  Dr.  J.  D.  Thomas  took  the  gas  and  went 
fully  under  its  influence,  and  their  blood  showed  no  change. 
By  passing  nitrous  oxide  through  the  blood,  the  death  line 
spoken  of  was  barely  visible,  but  after  adding  sulphide  of  am- 
monium it  was  clearly  seen. 

From  the  above  we  may  conclude  that  the  amount  of  pure 
nitrous  oxide  necessary  to  induce  anaesthesia  in  man  by  inhala- 
tion does  not  so  affect  the  blood  as  to  cause  any  alteration  on 
the  two  well-known  bands  in  the  green  portion  of  the  spectrum. 
In  other  words,  that  the  micro-spectroscope  gives  no  evidence 
that  radical  change  in  the  myohaematin  cr3^stalline  is  produced 
by  the  inhalation  of  nitrous  oxide  gas. 

Additional  Facts  in  Reference  to  the  Physiological 
Action  of  Xitrous  Oxide. 

Some  valuable  facts  have  recently  been  brought  before  the 
profession*  in   regard  to  this   anaesthetic  confirmatory  of  the 

*  On  the  Physiological  Action  of  Nitrous  Oxide.     By  Dudley  W. 


76  ARTIFICIAL    ANAESTHESIA. 

views  which  we  and  the  late  Dr.  I.  H.  McQuillen  have  before 
published  in  our  work  as  early  as  1878. 

Nitrous  oxide  {a)  is  said  to  produce  a  state  which  we  term 
ancesfhesia — a  loss  of  sensation  ; 

(b)  it  initiates  certain  emotional  states,  provoking  a  sensation 
of  exhilaration  and  well  being ;  in  fact,  it  plaj's  the  role  of  a 
stimulant; 

(c)  it  gives  rise  to  modifications  of  the  respiratory,  and 

(d)  circulatory  systems ; 

(c)  and  provokes  marked  muscular  movements,  which  may  be 
roughly  classed  as  (i)  rigidity  or  contracture  and  (ii)  jactitations. 

These  are,  speaking  broadly,  the  effects  of  nitrous  oxide  upon 
the  mammalian  organism,  and  in  attempting  to  explain  them 
we  must  ascertain  their  relations  among  themselves. 

A  further  fact  is,  that  Dr.  Buxton  has  observed,  and  his 
views  are  in  harmony  with  most  of  the  authorities  upon  the 
subject,  that  during  the  stage  immediately  anterior  to  the  loss 
of  consciousness,  persons  under  the  influence  of  nitrous  oxide 
are  hypercesthetic. 

Nitrous  oxide  does  induce  hypergesthesia.  The  cerebro- 
spinal axis — at  least  as  far  as  sensation  goes — is  the  seat  of  the 
changes  which  nitrous  oxide  induces,  and  which  culminate  in  the 
complete  abeyance  of  consciousness.  In  this  connection  he 
draws  attention  to  the  convenience  of  grouping  the  brain  phe- 
nomena, due  to  nitrous  oxide,  in  three  periods  :  the  period  be- 
fore unconsciousness,  which  he  contends  is  the  hypergesthetic 
period ;  the  period  of  unconsciousness,  and  the  period  of  re- 
turning consciousness,  in  which  hallucinations  take  their  origin. 

(a)  The  nitrous  oxide  may  either  give  rise  to  other  bodies  by 
change  in  its  own  chemical  form  ;  or  (Ij)  acting  purely  in  a  me- 
chanical fashion,  it  may  upset  the  normal  equilibrium  of  the 
functions  of  respiration,  and  so  give  rise  to  accumulation  of 
aerial  fluids  in  the  blood,  which  would  normally  be  excreted. 

Buxton,  M.D.,  B.  S.  Lond.,  M.R.C.P.,  Administrator  of  Anaesthetics  in 
University  College  Hospital,  the  Hospital  for  Women,  Soho  Square, 
and  the  Dental  Hospital  of  London,  etc.,  1886.  Pamphlet,  pp.  22, 
Harrison  &  Sons,  St.  Mark's  Lane,  London. 


PHYSIOLOGICAL    ACTION    OF    XITROUS    OXIDE.        77 

(c)  It  mc\v  act  per  se^  and  exercise  a  specific  action,  just  as 
strychnine  or  anj'  otlier  body. 

At  one  period  it  was  believed  that  nitrous  oxide  acted  as  an 
oxidizing  agent  by  splitting  up  the  body  or  -tissues  into  oxygen 
and  a  residuum  of  nitrogen  compounds,  and  hence  came  into 
vogue  the  Apnoeal  or  Hyperoxygenation  theory  of  Colton.  In 
support  of  this  theory,  Stille  and  Maisch  urge  that  venous 
blood  is  arterialized  by  shaking  it  with  nitrous  oxide,  that  phos- 
phorus burns  in  it,  and  that  seeds  germinate  under  bell-jars  of 
nitrous  oxide.  Zimmerman,  whose  paper  we  have  not  been 
able  to  consult,  is  pledged  by  Stille  and  Maisch  to  the  statement 
that  pigeons  and  rabbits  will  recover  after  being  placed  in  the 
gas  for  eight  hours.  Of  course,  were  such  theories  true,  we 
should  have  to  admit  that  nitrous  oxide  is  a  respirable  gas.  In 
1872  Dr.  Frankland  came  to  the  conclusion  that  nitrous  oxide 
was  not  decomposed  during  its  sojourn  in  the  body,  basing  his 
opinion  upon  analyses  made  of  air  expired  by  rabbits  when  con- 
fined in  an  atmosphere  of  mixed  air  and  nitrous  oxide. 

Jolyet  and  Blanche,  who  published  their  results  in  Brown- 
Sequard's  "Archives  de  Physiologie,"  find  vegetables,  as  well 
as  animals,  die  incontinently  when  placed  in  an  atmosphere  of 
nitrous  oxide.  And  in  the  case  of  certain  seeds,  Dr.  Buxton 
has  failed  to  induce  germination  in  an  atmosphere  of  pure  ni- 
trous oxide.  Of  course,  combustion  will  take  place  in  nitrous 
oxide,  provided  the  heat  be  sufficient  to  produce  "the  mode  of 
motion  "  in  the  molecules  of  the  gas,  which  leads  to  their  dis- 
integration ;  but  experiment  has  shown  that  the  heat  of  the 
blood  is  insufficient  to  initiate  such  a  dissociation.  Bonwill's 
suggestion  of  rapid  breathing  to  produce  anaesthesia  probably 
acts  rather  through  the  changes  it  produces  in  the  blood-pressure 
of  the  cerebral  circulation  or  nervous  exhaustion  than  by  dint 
of  hyperoxygenation.  When  an  animal  is  killed  by  nitrous 
oxide,  the  blood,  if  examined  within  two  minutes  after  death, 
gives  the  well-known  spectrum  of  reduced  hcemoghhin,  while 
the  muscles  give  the  corresponding  one  of  reduced  myolicematin, 
but  not  during  the  anccsthetic  stage.  Here  we  are  dealing 
not  with  nitrous  oxide  blood  effects,  but  these  complicated  and 
probably  overridden   by  asphyxial  effects.     Another  possible 


78  ARTIFICIAL    ANyESTHESIA. 

way  by  which  nitrous  oxide  may  be  introduced  into  the  organ- 
ism is  by  means  of  the  nitrites,  thus  forming  combinations 
with  the  coloring  matter  of  the  blood,  producing  oxyhaemo- 
globin. 

Bernard,  whose  classical  work  on  asphyxia  gives  the  fullest 
account  of  that  condition,  speaks  of  three  forms  of  asphyxia  : 

(1.)  That  arising  from  inhalation  of  irrespirable  gases  which 
are  themselves  harmless.  To  this  class  many  authorities  would 
relegate  nitrous  oxide. 

(2.)  That  due  to  poisonous  vapors,  such  as  carbonic  monoxide, 
sulphuretted  hj^drogen,  and  carburetted  hydrogen. 

(3.)  Asphyxia  from  want  of  air,  such,  for  example,  as  would 
ensue  upon  the  ligature  of  the  trachea.  He  subsequently  points 
out,  with  justice,  that  asphyxia  resulting  from  inhalation  of  an 
indifferent  irrespirable  gas,  and  that  due  to  want  of  access  to 
air,  are  in  fact  one  and  the  same  condition. 

The  arterial  blood,  becoming  gradually  deoxidized  by  parting 
with  its  oxj^gen  to  the  tissues,  acts  upon  the  medulla  respiratory 
centres ;  hence  follows  hyperapnoea.  This,  in  the  case  of  some 
persons  subjected  to  experiments  by  Drs.  Burdon  Sanderson, 
John  Murray  and  Mr.  J.  Smith  Turner  (who  caused  them  to 
respire  pure  nitrogen),  did  not  occur  for  about  two  minutes  after 
commencement  of  inhalation. 

The  Phenomena  of  the  So-called  Asphyxia  of  Ni- 
trous Oxide  Narcosis. — In  the  first  place  we  find  a  tolerably 
uniform  increase  in  the  number  and  depth  of  respirations.  Dr. 
Buxton  has  not  yet  succeeded  in  detecting  any  excess  of  expira- 
tory over  inspiratory  movements.  The  respirations  are,  more 
correctly  speaking,  simply  an  exaggeration  of  the  normal,  quite 
regular,  but  hurried  in  rhythm  and  increased  in  depth.  This 
begins  certainly  within  half  a  minute — usually  within  fifteen 
seconds — from  the  commencement  of  nitrous  oxide  inhalation. 
The  respirations,  however,  become  slower  as  narcosis  proceeds, 
and  finally  stertor  supervenes,  which  frequently  is  followed  by  a 
period  of  complete  respiratory  calm,  no  thoracic  movements  ap- 
pearing. A  few  seconds  more  and  respirations  are  recom- 
menced, and  the  person  passes  quietly  into  ordinary  breathing. 
He  has  never  observed  anything  which  in  the  slightest  degree 


PHYSIOLOGICAL  ACTION  OF  NITROUS  OXIDE.    79 

resembles  the  expiratory  convulsions  one  is  so  familiar  with  in 
the  case  of  tlie  lower  animals  killed  by  asphyxia.  These  results 
will  go  to  strengthen  the  present  theory  that  nitrous  oxide, 
pushed  to  the  extent  of  narcosis,  does  not  give  rise  to  circulatory 
changes  at  all  comparahle  to  those  occurring  in  the  course  of 
asphyxia.  The  results  obtained  by  the  cardiograpli  in  the 
human  subject  have  not  been  encouraging,  and  Dr.  Buxton  is 
determined  to  investigate  the  exposed  hearts  of  mammals  as 
likely  to  render  a  more  reliable  record.  In  this  connection  the 
experiments  of  Amory,  Krishaber,  Goldstein  and  Kuntz  are  of 
interest.  These  observers  found  that  animals,  when  subjected 
to  the  vapors  of  nitrous  oxide,  after  a  time  died.  Now  it  is 
important  to  notice  that  the  animals,  when  made  the  subject  of 
a  post-mortem  examination,  revealed  the  usual  signs  of  as- 
phyxia! poisoning.  But  this  is,  of  course,  wholly  different  from 
death  from  nitrous  oxide.  In  these  animals  nitrous  oxide  nar- 
cosis was  followed  by  suffocation,  air  ivas  excluded,  and  hence 
asphyxia  ensued.  It  has  happened  to  skilled  anaesthetists  to 
have  a  necessity  of  maintaining  nitrous  oxide  narcosis  for  a  con- 
siderable time.  This  has  been  done  by  allowing  the  patient  to 
respire  air  at  long  intervals.  In  this  way  a  really  prolonged  nar- 
cosis can  be  effected  while  we  are  seeking  only  to  promote  the 
action  of  nitrous  oxide  upon  the  nervous  centres. 

The  true  test,  and  one  of  great  value,  is  the  examination  of 
the  blood  shed  during  anaesthesia,  performed  by  the  writer  in 
conjunction  with  the  late  Professors  McQuillen,  Richardson  and 
C.  S.  Turnbull,  gas  being  administered  by  Dr.  Thomas.  We 
may  then  conclude  that  pure  nitrous  oxide  produces  narcosis  by 
virtue  of  other  than  asphyxiating  qualities. 

This  gas,  then,  enters  the  blood  through  the  lungs  and  exer- 
cises a  certain  specific  action  upon  the  nervous  centres.  And 
here  we  have  a  ready  explanation  of  an  otherwise  most  anoma- 
lous circumstance,  viz.,  that  in  a  certain  number  of  cases,  per- 
sons evince  the  utmost  toleration  of  nitrous  oxide  and  resist  the 
nepenthal  action  for  a  minute  or  more.  Were  nitrous  oxide 
purely  an  asphj^xiant,  we  should  invariably  narcotize  our  pa- 
tients when  replaced  by  oxygen,  but  such  is  not  the  case — in 
fact,  they  are  narcotized  before  this  oxygoi  is  exhausted. 


80  ARTIFICIAL    ANAESTHESIA. 

Nitrous  oxide  enters  the  blood  by  producing  an  anaesthesia 
with  no  combinations,  except  the  broad  one  between  Fraun- 
holfer's  D  and  E  lines  which  represents  the  spectrum  of  re- 
duced haemoglobin.  It  then  passes  to  the  nerve  centres  as 
venous  blood,  plus  some  stimulating  and  narcotic-influence,  and 
gives  rise  to  subjective  exhilaration.  Upon  the  heart  it  acts  as 
an  accelerator.  At  this  time  the  inhibitory  centres  are  in  a  state 
of  at  least  lessened  activity,  as  is  evidenced  by  involuntary 
movements,  micturition,  etc.  ;  later  the  reflexes  are  lost.  Dur- 
ing this  stage  the  blood  pressure  would  appear  to  be  lessened, 
the  action  of  the  heart  accelerated,  and  the  respiratory  rhythm, 
at  first  quickened,  subsequently  slowed  to  a  standstill.  This 
state  of  things  persists  for  awhile,  and  is  accompanied  by  relax- 
ation of  some  muscles,  e.g.^  the  palatine  and  faucial  muscles, 
while  other  muscles  are  the  seat  of  arhythmic  clonic  and  tonic 
contractions.  Following  upon  this  stage  we  usually  meet  with 
the  phenomena  of  recovery.  During  this  period  a  further  stage 
of  excitement  appears,  and  it  is  commonly  associated  with  hal- 
lucinations—sometimes pleasant,  sometimes  extravagant.  The 
sense  soon  becomes  keenly  upon  the  alert,  and  operative 
measures  prolonged  into  this  period  give  rise  to  the  most  intense 
pain.  Patients  will  declare  the  pain  in  such  cases  transcends 
that  where  no  gas  is  given. 

Dr.  Halliburton,  Assistant  Professor  of  Physiology  in  Uni- 
versity College,  was  good  enough  to  examine  some  blood  for 
Dr.  Buxton,  and  he  concurs  in  the  results  given  above.  These 
confirm  our  own  experiments  and  observations. 

Dr.  Buxton  was  anxious  to  undertake  experiments  to  ascer- 
tain whether  or  not  nitrous  oxide  jjvoduced  physical  changes 
in  the  conditions  of  the  brain,  which  were  made,  by  the  kind- 
ness of  Professor  Victor  Horsley,  at  the  Brown  Institution, 
London. 

The  skull  of  a  medium-sized  dog  was  trephined  and  nitrous 
oxide  gas  given  through  a  tracheal  tube  fitted  with  a  very  freely- 
acting  expiration  valve.  The  trephine  hole  exposed  the  outer 
third  of  the  sigmoid  gyrus  on  the  right  side.  Under  normal 
conditions  the  brain  was  seen  some  measurable  distance  beneath 
the  bone,  pulsating  quietly  and  synchronously  with  the  respira- 


PHYSIOLOGICAL    ACTION    OF    NITROUS    OXIDE.        81 

tion.     The  color  of  the  brain  covered  with  pia  mater  was  pinky- 
red,  or,  more  exactly,  vermilion. 

As  soon  as  the  animal  began  to  breathe  nitrous  oxide,  the 
respiratory  rhythm  being  interfered  with,  the  brain  pulsations 
became  more  notable  and  somewhat  hurried.  When  the  gas 
was  pushed,  and  the  animal  made  to  take  it  freely,  the  brain 
substance  was  seen  to  swell  up  and  gradually  reach  the  trephine 
hole.  The  color  now  began  to  change,  and  a  dark,  blue-red 
shade  appeared  to  creep  over  the  exposed  brain,  robbing  the 
brightness  of  the  vermilion  and  replacing  it  by  a  laky  purple. 
The  brain  undulations  were  at  this  stage  found  to  lessen  in  fre" 
quency  and  amplitude.  The  brain  substance  still  increased  in 
volume,  and  even  protruded  without  the  trephine  hole,  almost 
motionless,  and  of  a  pearly,  glistening  lustre  of  bluish  hue. 
The  vessels,  examined  with  a  strong  lens,  presented  the  well- 
known  look  of  commencing  stasis.  At  this  stage  the  nitrous 
oxide  was  stopped,  and  the  animal  allowed  to  inspire  air  freely. 
Quietly  and  gradually  with  each  successive  breath  of  air  the 
brain  receded,  the  undulations  returning  and  resuming  their 
normal  rhythm  and  range.  With  these  changes  came  a  return 
of  the  vermilion  tinge  which  characterizes  the  healthy  brain 
substance.  This  experiment  was  repeated ;  in  some  cases  the 
animal  was  anaesthetized  by  means  of  a  face-piece  with  an 
expiration  valve,  and  in  others  a  tracheal  tube  was  introduced  ; 
but  the  phenomena  observed  was  strikingly  uniform.  It  was 
next  determined  to  conduct  a  control  experiment,  first  pushing 
tlie  nitrous  oxide  to  the  verge  of  death,  and  subsequently  produc- 
ing asphyxia  by  deprivation  of  all  air.  The  gas  was  pushed 
until  respiratory  movement  completely  ceased.  In  a  little  over 
a  minute  (1  min.  10  sec.)  the  brain  substance  had  become  livid 
and  swollen  to  above  the  calvarial  edge.  The  animal  was  abso- 
lutely insensible  to  painful  sensation  ;  his  limbs  showed  marked 
jactitations.  In  about  1  minute  30  seconds  normal  respiratory 
movements  had  ceased.  Artificial  respiration  was  j^roniptJy  re- 
sorted to,  and  speedily  the  natural  thoracic  movements  were  re- 
sumed. The  trachea  was  then  occluded  and  the  brain  observed. 
In  about  a  minute  the  brain  substance  assumed  a  deep  purple, 
dull  hue,  which  in  another  half-minute  became  very  intense ; 


82  ARTIFICIAL    ANAESTHESIA. 

the  brain  then  began  to  recede,  sinking  deeply  from  the  trephine 
hole.  In  two  minutes  the  sphincters  became  relaxed,  and  fur- 
ther sinking  of  the  brain  took  place.  In  three  minutes  the  res- 
pirator}'  movements  were  very  profoundly  interfered  with,  only 
manifesting  themselves  by  long-drawn  gasps,  which  were  sepa- 
rated by  long  intervals.  In  five  minutes,  although  all  respira- 
tory movements  had  ceased,  the  heart  still  beat.  In  six  minutes 
access  of  air  was  allowed,  but  artificial  respiration  failed  to  efi"ect 
recovery. 

These  experiments  appear  peculiarly  instructive,  firstly,  as 
showing  in  a  very  marked  way  the  diiFerence  between  the  brain 
condition  when  fed  with  nitrous  oxide-laden  blood,  and  when 
supplied  with  deoxidized  blood  containing  tissue  refuse  ;  and 
secondly,  when  viewed  in  relation  with  the  clinical  phenomena 
of  nitrous  oxide  narcosis.  As  Dr.  Buxton  has  pointed  out,  there 
is  a  zone  of  hyperaesthesia  which  separates  the  normal  conscious- 
ness from  the  absolute  loss  of  sensation  on  the  one  hand,  and  on 
the  other  which  unites  the  stage  of  oblivion  or  sleep  with  the 
return  to  full  mental  activity.  It  is  presumably  at  this  epoch 
that  the  dreams  of  mental  exaltation  and  physical  joy  occur, 
and  it  is  then  that  slight  external  physical  stimuli — e.g .^  a  flash 
of  light,  a  noise,  a  movement — will  become  a  thousandfold  mag- 
nified and  perverted  in  the  patient's  brain.  The  peculiar  filling 
of  the  brain  would  seem  to  offer  a  physical  counterpart  for  these 
mental  conditions,  and  apparently  so  rapidly  modifies  the  brain 
cells  that  they  are  incapable  of  further  reception  or  ideation  ; 
an  initial  increased  exaltation  gives  way  to  a  complete  abeyance 
of  function. 

Experiments  in  the  same  lines  were  also  made  with  regard  to 
the  action  of  nitrous  oxide  upon  the  spinal  cord.'^  The  aniraa] 
being  under  the  influence  of  chloroform  and  curare,  the  laminae 
of  the  lower  dorsal  and  lumbar  vertebrae  were  removed  and  the 
cord  exposed  lying  in  the  spinal  canal.     The  animal  was  then 


*  These  experiments  were  made  at  the  University  College  Physio, 
logical  Laboratory,  and  Dr.  Buxton  was  indebted  to  Mr.  John  Rose 
Bradford,  B.Sc,  for  their  execution,  and  to  Professor  Schafer  for  the 
use  of  the  laboratory. 


EXPERIMENTS    UPON    BRAIN    AND    SPINAL    CORD.       83 

made  to  respire  nitrous  oxide,  only  expiring  through  a  slit  in 
the  canula.  A  very  marked  effect  soon  showed  itself  ;  the  cord 
gradually  enlarged  and  cerebro-spinal  fluid  began  to  well  out, 
showing  the  enlargement  of  the  whole  length  of  the  cord.  This 
experiment  was  repeated,  and  the  same  result  was  alwaj's  ob- 
tained. However,  as  will  readily  occur  to  you,  two  causes  might 
have  conceivably  produced  this  eifect,  namely,  (1)  the  exclusion 
of  oxygen,  i.e.,  the  asphj^xia,  or  (2)  the  presence  of  nitrous 
oxide.  To  test  which  of  these  possible  factors  was  really  re- 
sponsible for  the  swelling  of  the  cord,  the  animal  was  deprived 
of  air,  and  no  nitrous  oxide  given.  At  first  the  cord  remained 
unchanged — at  least  no  swelling  took  place,  and  no  escape  of 
cerebral-spinal  fluid  occurred.  Soon,  however,  as  the  blood 
became  more  and  more  deoxygenized,  the  cord  grew  smaller, 
shrinking  below  its  former  level  in  the  spinal  canal.  There  was 
no  doubt  but  while  in  nitrous  oxide  administration  the  cord, 
like  the  brain,  grew  larger,  in  asphyxia  it  shrank.  To  test  this 
effect  further,  the  following  crucial  experiment  was  tried.  The 
animal  was  subjected  to  asphyxia,  and  the  cord  was  watched 
until  it  had  perceptibly  shrunk,  when  nitrous  oxide  was  allowed 
to  enter  the  lungs.  If.  as  we  assumed,  nitrous  oxide  was  capable 
of  dilating  the  vessels  of  the  cord  when  acting  upon  them  in  a 
normal  condition,  it  was  thought  that  it  should  produce  a  like 
effect  when  the  cord  vessels  were  contracted  by  asphyxia.  The 
experiment  confirmed  this  supposition,  for  as  soon  as  the  animal 
had  its  lungs  well  saturated  with  nitrous  oxide,  the  cord  was 
seen  to  expand  and  the  cerebro-spinal  fluid  began  to  escape. 

Cod  elusions  of  Experiments  upon  the  Brain  and 
Spinal  Cord  with  Nitrous  Oxide  Gas. 

In  brain  and  cord  alike  we  meet  with  dilatation  of  the  vessels, 
with,  of  course,  an  inci'eased  blood  supply  to  the  nerve-centres. 
Such  a  condition  would  be  favorable  to  the  dissociation  of  ner- 
vous energy,  but  this  would  soon  be  followed  by  over-distension 
and  interference  with  due  regularity  of  the  cerebral  and  cere- 
bellar circulation  subversive  of  ideation  and  the  performance  of 
adjusted  muscular  action.  The  interference  to  the  cord  circu- 
lation must  also  interfere  with  the  due  conduction  along  its  path 


84  ARTIFICIAL    ANAESTHESIA. 

as  well  as  with  the  correlation  between  its  parts  and  the  higher 
brain  centres.  At  present  we  may  not  be  in  a  position  to  theo- 
rize beyond  the  broad  general  statements  given  above,  but  Dr. 
Buxton  thinks  we  may  justly  recognize  in  the  interference  with 
the  circulation  of  the  brain  and  spinal  cord,  produced  by  the 
inhalation  of  nitrous  oxide,  a  phenomenon  which  accounts  for 
not  only  the  every-day  experience  we  meet  with  in  giving  the 
gas  to  human  beings,  but  also  to  those  abnormal  cases  which 
occur  more  rarely  and  evince  marked  nervous  exhaustion  or 
irregular  outbursts  of  nervous  energy.  But  of  these  facts  we 
will  speak  again. 

The  development  of  nervous  symptoms  certainly  varies  largely 
with  the  initial  state  of  the  nervous  protoplasm,  for  while  in 
some  persons  nitrous  oxide  produces  marked  nerve  disturbance, 
in  others  it  brings  about  none  whatever. 

The  Reflexes  under  Nitrous  Oxide. 

Among  reflexes  it  is  usual  to  consider  two  classes,  skin  or 
superficial  reflexes,  of  which  a  famihar  example  is  found  in  the 
conjunctival  reflex,  and  deep,  of  which  we  have  examples  in 
ankle  clonus  and  the  patellar  jerk  and  front  tap  reaction.  In 
health,  and  under  normal  functional  conditions,  the  superficial 
and  the  patellar  reflexes  are  present ;  certain  pathological  condi- 
tions lessen  or  exaggerate  these  reflexes  and  cause  the  develop- 
ment of  ankle  clonus.  The  presence  of  ankle  clonus  points 
always  to  disease  or  functional  derangement  of  the  spinal  cord. 
Now,  nitrous  oxide  produces  very  marked  derangement  of  the 
reflexes.  In  October,  1883,  Professor  Horsley*  drew  attention 
to  the  persistence  of  the  patellar  phenomena  under  profound 
anassthesia,  and  long  after  the  disappearance  of  the  superficial 
reflexes.  Clonus  has  been  found  to  be  developed  in  a  number 
of  cases,  although  it  is  not  a  constant  phenomenon  of  nitrous 
oxide  narcosis ;  hence  this  gas  not  only  abrogates  the  function 
of  the  brain  centres,  but  also  produces  marked  disturbance  in 
the  cord,  while  it  blunts  or  obliterates  peripheral  sense. 

What  the  exact  nature  of  this  derangement  of  the  cord  func- 

"•••  Brain,  vol.  vi.,  p.  369  et  seq. 


THE    REFLEXES    UNDER    NITROUS    OXIDE.  85 

tion  is  we  cannot  venture  at  present  to  offer  an  opinion  ;  we  can 
onl}'  study  it  by  means  of  the  phenomena  it  reveals.  These 
also  are  various,  differing,  it  would  appear,  according  to  the 
stability  of  the  nervous  centres  of  the  individual  subjected 
to  observation.  Nor  is  this  surprising  when  we  remember 
that  the  effects  are  very  transitory,  and  must  be  largely  influ- 
enced by  collateral  circumstances.  The  more  constant  cord 
phenomena  are — rigidity  of  the  muscles,  which  passes  into 
complete  flaccidity  ;  jactitations,  which  appear  rythmic  and 
general ;  loss  of  superficial  reflexes  ;  i^ersistence  of  knee  jerk. 
Among  the  occasional  phenomena  we  may  reckon — ankle 
clonus ;  opisthotonus  and  emprosthotonus ;  paralysis  of  the 
bladder  and  defecation  centres,  and  involuntary  and  uncon- 
scious passage  of  urine  and  faeces ;  probably,  excitation  of  the 
sexual  centres,  and  abolition  of  the  normal  checks  imposed 
upon  the  production  of  orgasm.  Further,  we  must  reckon  the 
secondary  results  apparently  due  to  a  more  lasting  cord  effect, 
as  seen  in  paresis  or  even  paraplegia  following  nitrous  oxide 
inhalation.  Many  of  these  phenomena  are  confessedly  rare, 
and  are  perhaps  only  elicited  in  nervous  systems  predisposed  to 
take  on  the  condition,  whatever  it  may  be,  which  nitrous  oxide 
induces.  In  some  respects  nitrous  oxide  would  appear  to  hold 
comparison  with  strychnine.  The  rigidity,  with  the  occasional 
liberation  of  irregular  and  disorderly  explosions  of  nerve  energy, 
occur,  although  with  different  degrees  of  persistence,  alike  with 
one  and  the  other  drug.  This  would  perhaps  give  a  clue,  and 
suggest  that  under  nitrous  oxide  the  higher  ideomotor  centres 
lose  control,  the  resistances  throughout  the  cord  are  lessened, 
and  the  cells,  deprived  of  the  normal  restraints  imposed  by 
habitual  and  associated  action,  tend  to  irregular  explosive  out- 
bursts. It  seems  at  least  probable  that  under  nitrous  oxide  not 
only  do  we  meet  with  a  stage  of  preliminary  exaltation  of  func- 
tion, misdirected  indeed,  and  unconstrained  by  judgment,  in 
the  brain  centres,  exemplified  by  the  stage  of  hyper^esthesia 
spoken  of  above,  but  that  in  the  lower  cord  centres  we  recog- 
nize a  similar  initial  heightening  of  activity,  also  irregular 
and  disorderly,  followed  by  cessation  of  their  functions.  In- 
deed,  Dr.   Buxton   ventures   to   think   the   same   sequence   of 


S6  ARTIFICIAL    ANESTHESIA. 

events  happens  in  the  vital  centres,  and  that  this  explains 
much  of  what  follows  in  the  remarks  made  upon  blood  pres- 
sure, cardiac,  and  respiratory  rhythm.  But  although  we  may 
not  as  yet  go  far  enough  to  dogmatize  upon  what  is  the  nature 
of  this  action  upon  the  cerebro-spinal  axis,  yet  it  seems  conso- 
nant with  our  facts  to  regard  it  as  sedative,  which,  while  pro- 
voking an  initial  exaltation  of  function,  eventually  plunges  the 
tissues  into  a  sleep,  or  state  like  the  long  dose  of  hibernation. 
Certain  it  is,  in  some  cases  one  meets  with  a  quiet  prolongation 
of  nitrous  oxide  narcosis,  unaccompanied  by  the  wild  convul- 
sions of  asphyxia,  when  the  breathing  absolutely  stops  while 
the  heart  still  beats  on.  In  this  state  presumably  the  cord 
centres  have  gradually  yielded,  and,  the  medulla  reached,  the 
respiratory  centre  has  also  peacefully  ceased  from  work,  and 
the  patient  is  entranced  alike  in  his  mental  and  vegetative 
functions.  In  these  cases  artificial  respiration,  conducted  for 
one  or  two  admissions  of  air,  restores  the  patient  to  animation, 
and  all  goes  well.  No  danger  is,  in  fact.,  incurred,  unless  the 
ancesthetist  is  either  incompetent  or  negligent  of  his  solemn 
charge.  It  seems  hardly  worth  while  to  do  more  than  to  beg 
you  to  compare  mentally  these  phenomena  with  those  afforded 
when  asphyxia  terminates  life.  To  contrast  what  has  just  been 
described  with  the  mental  activity  persisting  almost  to  the  last 
gasp,  the  purposeless  struggles,  the  vnld,  chaotic  respiratory 
efforts,  the  frantic  ivrithings  of  the  voluntary  muscles,  and  at 
length  the  general  massive  convulsions  passing  into  a  false  quiets 
marked  by  an  occasional  gathering  together  of  the  failing 
nervous  energy  to  effect  a  spasmodic  explosion  of  muscular  force. 

The  Induction  of  Anesthesia  in  Heart  Failure. — It  is 
a  matter  of  very  great  importance  for  us  to  determine  the 
behavior  of  nitrous  oxide  towards  the  heart  and  vascular  system 
in  general.  Dr.  Buxton's  and  our  own  investigations  in  this 
direction  have  been  made  to  ascertain  the  action  of  the  heart, 
and  the  variations  of  blood  pressure  under  nitrous  oxide ;  and 
further,  to  determine  how  far  the  variations  seen  when  nitrous 
oxide  was  exhibited  were  due  to  that  body,  and  how  far  to  the 
coincident  deprivation  of  oxj^gen. 

The  animals  selected  were  dogs  and  cats,  but  as  the  results 


THE    REFLEXES    UNDER    NITROUS    OXIDE.  87 

were  practically  uniform,  it  is  unnecessary  to  particularize  the 
experiments.  Dr.  Buxton  dwells  on  his  great  indebtedness  to 
his  friends,  Professor  Victor  Horsley,  Mr.  Bradford,  and  Pro- 
fessor Schafer,  through  whose  kindness  alone  the  research  was 
practicable. 

The  heart's  action  under  nitrous  oxide  does  not  become  much 
affected,  and  even  in  cases  in  which  that  gas  is  pushed  until 
complete  cessation  of  respiratory  movements  occur,  the  heart 
still  continues  to  beat,  its  action  gradually  growing  weaker.  In 
no  case  have  we  seen  any  tumultuous  action  of  the  heart  or  a 
sudden  cessation,  only  the  gradual  sinking  to  rest  noticed  above. 
The  attempt  at  narcotizing  animals  and  timid  persons  produces 
a  temporary  acceleration  of  heart  beat,  but  as  soon  as  the  intel- 
lect becomes  under  the  influence  of  the  narcotic  this  acceleration 
passes  off,  and  the  heart  beats  become  regular,  strong  and 
somewhat  slowed.  It  will  be  remembered  that  these  results 
are  in  accord  with  the  statements  already  published,  and  based 
upon  numerous  sphj^gmographic  tracings  taken  of  the  human 
radial  pulse. 

The  blood  pressure  under  nitrous  oxide  inhalation  has  the 
following  peculiarities :  For  the  first  period  it  shows  little 
change,  but  subsequently  a  fall  of  pressure  takes  place.  Upon 
allowing  the  animal  to  inhale  air,  the  blood  pressure  recovered 
itself,  but  only  gradually,  and  by  passing  through  a  phase  of 
somewhat  irregular  curves.  These  curves  are  not  respiratory, 
as  thej'  take  place  even  when  the  animal  is  completely  paralyzed 
with  curare,  and  artificial  respiration  is  maintained.  In  some 
cases  a  slight,  but  very  slight,  rise  in  the  blood  pressure  took 
place,  but  a  rise  of  blood  pressure  which  persists  for  a  notable 
time  appears  always  to  follow  the  nitrous  oxide  inhalation. 
Control  experiments  were  conducted  to  test  the  effect  upon 
blood  pressure  when  the  animal  is  deprived  of  air.  These  were 
done  upon  curarized  animals  in  order  to  avoid  the  interference 
caused  by  dj^spnoeic  convulsions.  As  soon  as  the  air  supply 
was  cut  off,  the  blood  pressure  began  to  go  up,  and  rapidly  in- 
creased until  the  heart's  action,  which  lessened  in  force  pari 
passu  with  the  heightened  blood  pressure,  became  so  weak  that 
it  was  necessary  to  allow  air  to  enter  the  lungs.     The  blood 


88  ARTIFICIAL    ANJ5STHESIA. 

pressure  then  resumed  its  normal  height  very  quickly,  but  the 
rise  which  follows  after  nitrous  oxide  administration  does  not 
appear  to  ensue  after  asphyxia. 

RevieAviiig-  Nitrous  Oxide  Experiments. 

Dr.  Buxton  and  the  author,  upon  revieiviiig  the  nitrous  oxide 
experiments,  and  controlling  them  by  the  asphyxia  experiments, 
prove  nitrous  oxide  itself  has  no  very  marked  influence  upon  the 
heart  or  vessels ;  what  action  it  has  is  to  steady  and  slow  the 
heart,  and,  if  anj^thing,  to  strengthen  it,  and  the  action  is  some- 
what prolonged.  The  vessels,  at  first  almost  unaffected,  later 
undergo  a  peripheral  dilatation  leading  to  a  lowering  of  blood 
pressure.  This,  however,  is  true  only  when  reservation  is 
made  ;  for,  as  we  shall  see,  the  splanchnic  vascular  areas  are 
contracted  at  first.  Upon  this  last  statement  I  have  some  addi- 
tional evidence  to  ofi"er.  A  good-sized  frog  (Rana  temporaria) 
that  was  placed  beneath  a  dome-shaped  glass  vessel,  was  so  ar- 
ranged that  the  web  of  one  foot  was  outside  the  vessel,  and 
could  be  examined  under  the  microscope.  The  dome  was  emp- 
tied of  air  and  kept  full  of  nitrous  oxide,  and  the  frog  carefully 
noted  while  the  web  was  examined.  It  was  necessary  to  keep 
the  whole  animal  in  nitrous  oxide,  as  cutaneous  respiration  is 
very  active  in  the  frog.  At  first  the  circulation  in  the  web  was 
found  to  be  slowed  ;  at  the  same  time  the  minute  vessels  were 
seen  to  dilate,  and  this  slowing  and  dilatation  both  became  more 
marked  as  time  went  on.  Changes  also  appeared  to  develop  in 
the  corpuscles,  by  which  they  took  on  a  flattened,  compressed 
appearance.  At  length  the  respirations,  which  had  become 
slower  and  slower,  became  almost  extinguished,  the  capillary 
circulation  in  some  areas  was  almost  in  a  condition  of  stasis, 
whilst  throughout  the  field  extreme  slowing  had  occurred.  At 
this  point  the  frog  was  allowed  free  access  to  air,  and  at  once 
the  respiration  quickened,  the  blood-flow  increased  in  rapidity, 
becoming  many  times  more  rapid  than  under  the  gas.  The 
corpuscles  resumed  their  normal  aspect.  The  results  of  such 
experiments  upon  the  frog  point  to  a  peripheral  dilatation  of 
capillaries,  and  of  this  further  evidence  has  yet  to  be  adduced. 
It  needs  no  argument  to  show  that  a  vascular  viscus,  like  either 


EXPERIMENTS  ON  THE  KIDNEY.         89 

the  kidney  or  the  spleen,  must,  under  variations  of  blood  sup- 
ply, undergo  variations  in  size.  If,  therefore,  it  were  possible 
to  inclose  either  viscus  in  an  air-tight  receiver  communicating 
with  an  oil  manometer,  it  would  give  indications  of  increase  or 
diminution  of  size  according  as  the  blood  supply  were  increased 
or  lessened.  Mr.  Bradford  has  kindly  enabled  us  to  investigate 
this  point  pretty  fully. 

Experiiiieiits  Avitli  Xitrous  Oxide  on  the  Kidney. 

The  experiments  made  upon  the  kidneys  were  tolerably 
numerous,  and  were  singularly  uniform  in  their  results.  The 
kidney  in  an  animal  narcotized  ivifh  nitrous  oxide  speedily  under- 
goes contraction^  icliicli  corresponds  of  course  icitJi  the  contraction 
of  the  renal  arteries.  This  contraction  continues  as  long  as  the 
nitrous  oxide  is  given,  but  as  soon  as  that  is  cut  off  and  the 
animal  respires  air  the  kidnej"  speedily  recovers  its  normal  size, 
but  no  dilatation  of  vessels  beyond  normal  takes  place.  With 
this  condition  we  have  to  compare  the  behavior  of  the  kidney 
in  an  animal  subjected  to  asphyxia.  Here  the  Tddney  undergoes 
a  dilatation  as  soon  as  the  air  is  cut  off.  This  corresponds  with 
dilatation  of  the  renal  arteries,  and  is  probably  due  to  increased 
heart  action  called  into  being  by  the  venosity  of  the  blood. 
Later,  when  the  heart  fails,  the  kidnej^  suddenly  contracts,  a 
very  rapid  fall  in  the  kidney  curve  occurring.  Thus  a  singu- 
larly striking  contrast  in  the  behavior  of  the  kidney  reveals 
itself,  according  as  that  viscus  is  influenced  by  nitrous  oxide  or 
asphyxia.  This  effect  upon  the  renal  circulation  must  not  be 
taken  as  militating  against  the  statements  made  above  with 
regard  to  the  general  blood  pressure  as  shown  by  the  carotid 
artery  and  about  the  circulation  in  the  brain  and  cord.  It  is 
well  known  that  certain  sedatives — morphine,  for  example — 
dilate  the  vessels  in  one  area  while  they  contract  those  of  other 
areas.  »• 

The  effects  produced  by  nitrous  oxide  upon  respiratory 
rhythm. 

The  chest  movement  will,  as  is  well  known,  continue  without 
any  air  entering  if  a  sufficientl}^  long  and  small  elastic  tube  be 
attached  to  the  tracheal  canula,  so  that  one  can  easily  compare 


90  ARTIFICIAL    ANESTHESIA. 

asphyxia  with  nitrous  oxide  narcosis.  In  the  last  condition 
the  respirations  are  at  first  quickened,  but  not  lessened  in 
depth ;  later  they  grow  slower  and  deeper,  and  still  later  they 
become  very  slow  and  somewhat  more  shallow ;  finally  they 
cease.  The  time  in  which  this  cessation  comes  about  varies 
considerably  in  animals.  /  have  not  seen  the  dyspnoeic  struggles 
under  nitrous  oxide  which  asphyxia  brings  about. 

Sphygniographic  Tracings  from  Patients  under  the 
Influence  of  Nitrous  Oxide  Gas.    (After  Mowat.) 

In  about  half  to  three-quarters  of  a  minute  the  patient's 
consciousness  is  lost,  and  soon  after  the  pupils  will  dilate,  the 
eyes  becoming  dull,  with  loss  of  expression,  and  there  may  be 
strabismus.  This  is  the  primary  condition  of  anaesthesia,  when 
if  the  conjunctiva  is  touched,  the  reflex  is  still  there,  and  yet  at 
this  stage,  a  single  tooth,  or  a  very  slight  operation  can  be  per- 
formed. If,  however,  the  inhalation  is  continued  for  a  minute 
longer,  the  breathing  becomes  stertorous,  muscular  movements 
of  the  hands  and  feet  take  place,  and  the  conjunctiva  can  be 
touched  without  any  movement.  Should  the  breathing  stop 
for  more  than  ten  seconds  air  must  be  given.  This  is  the  period 
of  deep  anaesthesia,  and  should  the  heart  intermit,  and  pulse 
at  the  wrist  not  be  felt,  air  must  be  introduced  and  the  gas 
stopped.  If  everything  remains  in  good  condition,  now  is  the 
time  for  operation. 

It  is  well  known  that  as  soon  as  the  inhaler  is  placed  over  the 
mouth  and  nose  of  the  patient  he  begins  to  respire  more  quickly 
and  his  pulse  increases  in  speed.  This,  however,  is  due  to  ex- 
citement resulting  from  the  fear  which  usually  accompanies  the 
inhalation.  As  soon  as  inhalation  begins  respiration  becomes 
slow,  the  tension  of  the  pulse  falls,  the  number  of  beats  per 
minute  is  increased,  the  tidal  or  predicrotic  wave  is  slightly 
better  marked,  and  the  dicrotic  wave  becomes  so  well  marked 
as  to  constitute  that  pulse  which  is  known  as  fully  dicrotic ; 
sometimes,  indeed,  it  is  even  slightly  hyperdicrotic.  As  anes- 
thesia proceeds  the  tension  of  the  pulse  falls  considerabl}'^, 
whilst  the  number  of  pulsations  increases.  The  tidal  and 
dicrotic    waves    still    remain    very   well    marked.     When    the 


SPHYGMOGRAPHIC    TRACINGS. 


91 


mouth-piece  is  removed  and  any  operation  is  to  be  performed, 
the  pulse  undergoes  a  marked  cliange.  This  is  probabl}^  due  to 
a  reflex  action  through  the  vagus  to  the  heart.  Immediately 
after  the  operation  the  pulse  gradually  assumes  its  normal  con- 


PL  ate  13.    (Figs.  1-3. 


Normal  pulse. 


Fully  under  nitrous  oxide  witli  lowering  of  arterial  tension. 


Tidal  wave  appearing. 


•dition,  passing  (in  the  reverse  order)  through  the  stages  it  had 
undergone  when  the  nitrous  oxide  gas  was  applied. 

As  a  matter  of  course,  every  patient  is  a  law  unto  himself 
as  regards  the  time  required  to  come  fully  under  the  influence 
of  the  anaesthetic,  and  even  the  same  individual  will  diff'er  at 
different  conditions  of  the  sj^stem. 

The  Committee  appointed  by  the  Odontological  Society  of 


92 


ARTIFICIAL    ANESTHESIA. 


Great  Britain  found  the  following  averages  in  a  large  number 
of  administrations  of  the  gas  : 


Time  going  off. 

Duration. 

Time  from  com- 
mencement to 
recovery. 

Males,     . 
Females, 
Children 

(under  15), 

1  min.  21  sec. 
1     ''     16   '' 
1     "       3   u 

24  sec. 

28     " 
22    '' 

1  min.  55  sec. 

2  " 

1     "     49    '^ 

In  human  beings  T  have  seen,  especially  in  children,  complete 
cessation  of  respiration  without  the  slightest  preliminary  strug- 
gle. Alike  in  the  lower  animals  and  man,  the  breathing 
recommences  if  pressure  is  made  on  the  chest.  These  changes 
in  respiration  are,  I  am  inclined  to  think,  due  wholly  to  the 
action  of  nitrous  oxide  upon  the  nerve  centres  presiding  over 
respiration. 

On  Blood  Alterations  l>y  Anaesthetic  Ag-ents— 
Conclusions. 

In  conclusion,  there  are  various  practical  considerations  which 
the  writer  thinks  may  well  be  taken  into  review  while  studying 
the  physiology  of  nitrous  oxide  narcosis. 

If  nitrous  oxide  acts  as  a  sedative  in  virtue  of  its  own  inherent 
properties,  and  does  not  owe  its  value  as  an  anaesthetic  to 
asphyxial  processes  called  into  play  by  concurrent  privation  of 
oxygen,  it  should  be  our  aim  to  push  the  gas  and  give  free  vent 
to  expired  gas.  We  should  see  that  our  patient  changes  as  freely 
as  possible  his  residual  air  during  inspiration,  and  expires  as 
freely  as  possible  the  refuse-laden  nitrous  oxide,  which  has  been 
stationary  within  the  air-spaces  during  the  last  respiration.  We 
cannot  but  think  that,  whatever  may  be  the  saving  of  gas 
brought  about  by  employing  supplemental  bags  wherein  the 
nitrous  oxide  is  collected  and  reinspired  a.gain  and  again,  the 
patient  suffers  thereby  from  the  double  evil  of  breathing  diluted 
and  impure  nitrons  oxide,  and,  further,  is  not  favorably  placed 


BLOOD    ALTERATIONS    BY    ANESTHETIC    AGENTS.       93 

for  exhaling  the  refuse  of  the  lungs.  We  should  incline  to 
attribute  to  this  method  the  cases  one  occasionally  meets  with  of 
severe  headache,  vertigo,  dizziness  and  other  untoward  symptoms 
consecutive  upon  nitrous  oxide  inhalation.  It  is  a  very  im- 
portant point  to  induce  very  free  inspirations  of  pure  nitrous 
oxide,  and  to  avoid  anything  like  inducing  partial  asphj^xia, 
and  in  practice  this  gives  the  best  and  most  satisfactory  re- 
sults. 

The  behavior  of  the  heart  under  nitrous  oxide  should  encour- 
age us  to  use  this  agent  freely,  and  during  its  administration  to 
icatch  rather  the  respiration  than  the  pulse,  since  it  would  ap- 
pear that  syncope,  if  it  occur,  occurs  secondaril}"  through  the 
luUing  to  sleep  of  the  respiratoi^  centres.  The  cases  in  which 
nitrous  oxide  has  been  said  to  kill  by  heart  failure  are  few,  and 
even  in  these  we  are  not  at  all  sure  that  the  fatal  faint  was  not 
due  to  fear  or  shock  incurred  by  a  nervous  system  already 
shaken  by  suffering,  and  rendered  still  more  obnoxious  to  shock 
by  an  imperfect  narcosis.  When  we  remember  the  period  of 
heightened  sensibility  which  precedes  complete  restitution  of 
consciousness,  we  can  easily  comprehend  the  terrible  jars  a  de- 
bilitated nervous  system  must  sustain  if  operative  procedure  be 
carried  on  into  this  stage.  Clover  long  ago  pointed  out  from 
his  vast  clinical  experience  that  patients  may  be  allowed  to  cease 
breathing,  and  yet  no  fear  need  be  entertained,  as  a  few  vigorous 
pressures  upon  the  thoracic  parietes  will  reinitiate  respirations. 
Now  we  accept  his  statement,  and  explain  it  under  physiological 
laws. 

There  are  other  practical  points  that  are  suggested  by  knowl- 
edge of  the  action  of  nitrous  oxide.  Of  these,  not  the  least 
important  is  that  the  erotism  called  into  existence  in  a  fairly 
large  proportion  of  patients,  and  controlled  only  in  a  few  by  the 
restraints  of  habitual  thought  and  judgment,  should  render  all 
persons  most  careful  to  avoid  possible  incrimination  through 
hallucination.  For  the  sake  alike  of  patient  and  operator,  a 
witness  should  always  be  within  earshot,  or  within  sight,  when- 
ever nitrous  oxide  is  administered. 

Again,  the  decided  action  this  anaesthetic  has  upon  the  nerve 
centres,  and  its  tendency  to  call  forth  irregular  explosions  of 


94  ARTIFICIAL    ANESTHESIA. 

nervous  energy,  might  by  some  be  taken  as  contra-indicatory  to 
its  employment  for  patients  who  are  the  subjects  of  epileptiform 
seizures.  We  do  not,  however,  think  we  can  with  justice  say 
that  the  giving  the  gas  renders  a  fit  more  likely  to  occur  than 
the  operation.  We  are  aware  any  strong  excitant  will  call  forth 
a  seizure,  whereas  the  sedative  action  of  the  nitrous  oxide  will, 
by  lessening  stimulation  from  without,  be  less  inclined  to  pro- 
voke the  attack. 

Nitrous  Oxide  in  General  Surgery. 

Dr.  L.  Macdonald,  of  Washington,  D.  C,  has  found,  while 
not  discarding  ether  and  chloroform,  nitrous  oxide  gas  capable 
of  producing  anaesthesia  of  a  degree  that  was  quite  satisfactory 
for  the  performance  of  such  prolonged  operations  as  breast  ex- 
tirpation, laparotomies,  hysterectomies,  amputations — indeed, 
almost  all  operations  in  surgery,  except  those  within  the  oral 
respiratory  tract,  whether  the  operation  required  two  minutes 
or  two  hours. 

It  cannot  always  be  relied  upon  to  produce  thorough  and 
complete  muscular  relaxation.  It  is  therefore  not  the  best  an- 
aesthesia for  use  in  the  examination  of  joints,  displacements, 
fractures,  etc.  From  the  point  of  economy  and  convenience  he 
has  found  it  is  far  inferior  to  other  anaesthetics,  as  each  pro- 
tracted operation  costs  about  two  dollars. 

We  have  published  in  our  third  edition,  p.  136,  that  as  early 
as  March,  1874,  Dr.  D.  H.  Goodwillie  published  a  paper,  which 
had  been  read  before  the  Medical  Library  and  Journal  Associa- 
tion of  New  York,  of  his  success  in  a  prolonged  surgical  opera- 
tion by  the  administration  of  nitrous  oxide  gas.*  On  April  20, 
1875,  C.  A.  Brackett,  D.M.D.,  of  Newport,  administered  the 
gas  (about  thirty  minutes)  for  Dr.  Squire  of  that  city  for  the 
removal  of  a  cancer  of  the  breast  (second  operation),  as  he  did 
not  dare  to  give  ether,  the  patient  being  so  debilitated,  f 

It  is  Dr.  Brackett's  impression  that  the  late  Dr.  J.  Marion 
Sims  was  among  the  earlier,  if  he  was  not  the  earliest,  to  use 

■•'■  Johnson's  Dental  Miscellany  in  March,  1874. 
t  Private  letters  of  Dr.  Brackett. 


NITROUS  OXIDE  AND  OXYGEN  AS  AN  ANAESTHETIC.       95 

nitrons  oxide  in  long  operations,  and  notably  in  uterine  andi 
abdominal  surgery.  His  knowledge  of  anaesthetic  agents  was, 
comprehensive  and  intimate,  and  the  nature  of  the  operation 
which  he  specially  performed  gave  him  strong  reasons  for  wish- 
ing to  avoid  the  vomiting  and  retching  following  the  use  of' 
ether.  There  probably  are  records  accessible  to  determine,  at 
least  approximately,  the  time  of  his  beginning  to  use  nitrous, 
oxide  in  his  practice.  However,  in  the  article  above  named,, 
page  224,  Dr.  Sims  says  : 

"Nitrous  oxide  has  been  used  in  general  surgery  by  many- 
eminent  surgeons  in  New  York,  Philadelphia,  Baltimore,  and 
elsewhere.  It  has  been  used  successfully  in  New  York  by  James 
R.  Wood,  Carnochan,  and  others.  The  late  Marion  Sims  has 
used  it  in  difficult  and  prolonged  operations  (ovariotomy)  re- 
quiring thirty,  forty,  fifty-seven  and  sixty  minutes,  and  in  one 
case  one  hour  and  fifty  minutes,  and  always  with  most  satisfac- 
tory results. ' ' 

The  reference  on  page  136  to  Dr.  Goodwillie's  article  should 
be  to  "Johnson's  Dental  Miscellany,  Vol.  I.,  No.  3,  p.  85." 

"Dr.  Brackett  appreciated  many  years  ago  the  fact,  that 
owing  to  the  necessity  of  suspension  of  administration  before 
operations  in  the  mouth  began,  nitrous  oxide  was,  in  a  sense» 
less  well  adapted  to  such  operations  than  it  is  to  almost  all  other 
minor  surgery.  Some  years  ago  he  was  permitted  to  address 
the  Newport  Medical  Society  on  the  subject  at  a  regular  meet- 
ing, urging  then,  as  he  had  done  many  times  privately  before 
and  since,  the  great  aid  and  comfort  that  nitrous  oxide  may  and 
should  be  to  general  practitioners  and  specialists,  other  than 
dentists,  in  multitudes  of  cases  occurring  every  day  in  which 
such  help  would  be  acceptable.  It  is  most  gratifying  to  him 
that  the  agent  is  gradually  winning  its  way  to  a  larger  useful- 
ness." 

Nitrous  Oxide  and  Oxyg^en  as  an  Anaesthetic. 

The  great  advantages  of  nitrous  oxide,  as  an  anaesthetic, 
have  induced  various  observers  to  endeavor  to  find  a  method  of 
administering  gas  continuously,  so  as  to  keep  up  the  anaesthetic 


96  ARTIFICIAL    ANAESTHESIA. 

influence  for  a  sufficient  length  of  time  for  the  performance  of 
surgical  operations. 

Paul  Bert,  some  years  ago,  made  experiments  with  animals 
in  a  chamber  of  compressed  air,  a  mixture  of  nitrous  oxide  and 
oxj^gen  being  inhaled.  He  found  that  anaesthesia  could  be  kept 
up  for  a  long  period,  and  he  urged  the  construction  of  such 
chambers  for  operating  upon  the  human  subject.  Some  few- 
experiments  were  made  in  minor  surgery,  but  nothing  was 
attempted  on  a  large  scale  on  account  of  the  bulk  and  ex- 
pense, etc. 

In  1881,  Dr.  Si  Klikovich,  in  St.  Petersburg,  made  some  ex- 
periments on  himself  with  a  mixture  of  nitrous  oxide  and  oxygen 
in  the  proportion  of  80  to  20,  without  any  increase  of  atmos- 
pheric pressure,  with  a  satisfactory  result.  Zweifel  soon  fol- 
lowed, and  later  Hillischer. 

Hewitt's  Apparatus. 

In  1892  I  received  from  my  friend,  Frederick  Hewitt,  M.D., 
of  London,  Lecturer  on  Anaesthetics  at  the  London  Hospital,  a 
pamphlet  in  which  he  gives  the  report  of  a  series  of  cases,  with 
a  description  of  his  apparatus  and  mode  of  using  the  same.  I 
have  had  also  the  opportunity  of  testing  his  instrument,  as  ex- 
aminer of  anaesthetics,  in  conjunction  with  Professors  Dorr  and 
Cryer,  at  the  Philadelphia  Dental  College. 

The  following  is  an  illustration  of  the  instrument,  with  a  de- 
scription : 

Hewitt's  New  Simplified  Portable  Apparatus  for 
Administering-  Nitrous  Oxide  and  Oxygen.* 

Directions  for  Use. — All  air  or  gas  should  first  be  pressed 
out  of  the  double  bag,t  the  indicator  turned  to   "air"   (see 

*See  Dr.  Hewitt's  paper  on  "Further  Observations  on  the  Use  of 
Oxygen  with  Nitrous  Oxide,"  in  The  Joicrnal  of  the  British  Dental 
Association  for  June  15th,  1894. 

fit  is  not  advisable  to  press  the  bags  too  tightly,  as  the  suction 
caused  by  the  sides  adhering  together  has  a  tendency  to  draw  the 
valves  in  the  delivery  tilbes  through  to  the  wrong  side. 


APPARATUS    FOR    ADMINISTERINa    NITROUS    OXIDE.       97 

Plate  20),  and  the  two  divisions  of  the  bag  nearly,  but  not 
quite,  filled  with  their  respective  gases,  by  rotating  the  foot 
keys.     No  further  addition  of  oxygen   will  be  needed.     The 

Plate  19. 


Apparatus  complete. 

face-piece  should  then  be  very  accurately  applied.  Air  will  be 
breathed  freely  through  the  apparatus.  The  valves  should  be 
heard  to  act,  otherwise  the  face-piece  is  not  fitting,  or  the 
patient  is  not  breathing  as  freely  as  he  should.     The  indicator 


98  ARTIFICIAL    ANESTHESIA. 

is  now  turned  to  "1,"  which  means  that  nitrous  oxide  with  a 
small  quantity,  possibly  1  or  2  per  cent.,  of  oxygen  will  be 
inhaled.  It  is  most  important  that  the  two  divisions  of  the 
double  bag  should  be  kept  equally  and  partly  distended,  as 
shown  in  Plate  19.  The  anaesthetist  must  therefore  keep  his 
foot  almost  constantly  turning  the  nitrous  oxide  foot  key  in 
order  that  the  two  parts  of  the  bag  may  remain  equal  in  size 
throughout.  After  two  or  three  breaths  at  "  1  "  the  indicator 
should  be  turned  to  "2,"  and  progressively,  after  every  two  or 
three  breaths,  to  "  3,"  "4,"  "5,"  "6,"  "7,"  "8,"  "9,"  or 
"10,"  according  to  the  type  of  patient.  In  children  and  very 
anaemic  persons  the  indicator  maybe  placed  at  "2,"  "3,"  or 
even  "4,"  to  start  with,  and  turned  to  a  fresh  number  every 
breath  or  two.  But  in  adults  in  good  health  less  oxygen  must 
be  given. 

Important. — As  it  is  essential  to  the  proper  working  of  the 
apparatus  that  all  the  four  valves  act  well,  and  the  ten  oxygen 
inlets  be  kept  entirely  clear,  it  is  recommended  that  the  appa- 
ratus be  taken  apart  from  time  to  time  and  the  condition  of 
these  ascertained. 

To  Examine  Oxygen  Inlets. — Take  out  the  three  milled 
head  screws,  remove  the  indicator  handle  with  detent  spring, 
replace  the  centre  screw  in  dial  side  of  stop-cock,  and  pull  out 
the  inner  drum.  If  any  of  the  openings  appear  to  be  clogged 
pass  a  piece  of  metal  wire  of  suitable  size  through  each  one 
until  quite  clear. 

Lubricating  Inner  Brum. — It  is  very  important  that  no 
grease  or  oil  be  put  on  that  part  of  the  drum  which  revolves 
immediately  over  the  oxygen  inlets.  Any  neglect  of  this  will 
cause  them  to  get  choked,  and  render  it  necessary  to  take  the 
apparatus  to  pieces  again. 

To  Examine  Valves  in  Delivery  Tubes.  —Slip  off  the 
necks  of  gas  bag  one  after  the  other,  the  valves  can  then  be 
drawn  out  of  the  tubes  by  the  finger.  In  replacing  them 
always  have  the  inlets  to  mixing  chamber  open,  to  avoid  the 
rubber  dies  being  forced  through  to  the  wrong  side. 

The  centre  screw,  which  keeps  in  position  and  regulates  the 
tension  of  the  detent  spring,  will  in  time  get  somewhat  slack ; 


APPARATUS    FOR    ADMINISTERING    NITROUS    OXIDE.       99 

it  should  then  be  screwed  up  again  to  the  necessary'  degree  of 
tightness. 

The  experience  of  many  observers,  but  especially  that  of 
Professor  Hillischer,  of  Vienna,  and  Dr.  Hewitt,  of  London, 
demonstrates  the  fact  that  a  mixture  of  oxygen  with  nitrous 
^ggw4  may  be  practically  utilized  as  an  anaesthetic,  and  that  such 

\  Plate  20. 


Indicator,  etc. 


a  mixture  is  in  all  respects  the  safest  and  most  satisfactory 
agent  at  our  command  for  minor  surgical  operations.  It  en- 
ables us  to  utilize  the  anaesthetic  feature  of  nitrous  oxide  with- 
out its  one  element  of  danger,  viz,  its  tendency  to  produce 
asphyxia.  While  the  records  show  that  the  asphyxial  factor 
of  nitrous  oxide  narcosis  is  but  a  slight  element  of  danger  in 
its  use — for  no  anaesthetic  has  been  so  largely  and  indiscrimi- 
nately used — it  is  still  important  that  we  should  take  advantage 


100 


ARTIFICIAL    ANAESTHESIA. 


of  any  means  which  will  successfully  eliminate  this  one  danger- 
ous feature.  The  method  and  apparatus  devised  by  Dr.  Hewitt 
fully  meet  all  practical  requirements,  and  though  somewhat 
more  complicated  than  the  ordinary  nitrous  oxide  apparatus,  is 
sufficiently  simple  and  convenient,  as  is  seen  in  the  drawing  he 
has  sent  us. 

In  our  own  experiments  we  have  found  that  it  takes  a  little 
longer  time  to  induce  ansesthesia  in  the  human  subject  by  the 
mixture  of  nitrous  oxide  with  ox3"gen  than  when  pure  nitrous 
oxide  is  used.  There  is  to  be  noted  in  this  connection  that 
while  it  takes  longer  to  induce  anaesthesia  with  the  oxygen  and 
nitrous  oxide  mixture  than  with  nitrous  oxide  alone,  the  result- 
ing anaesthesia  is  of  longer  duration  where  the  mixed  gases  are 
used. 

Dr.  Hewitt's  figures  relative  to  average  period  for  inhalation 
for  dental  operations  are  as  follows  : 


Average  Period  of 

Inhalation  for  Dental 

Operation. 

Average  Period 

of  Resulting 
Ansesthesia. 

NgO  per  se,    .     .      .     . 

NgO  -h  0  in  sufficient 
quantity  to  prevent 
all  asphyxial  symp- 
toms,       

About  51  seconds. 
About  110  seconds. 

30  seconds. 
44  seconds. 

In  typical  cases  of  ansesthesia  by  mixed  oxygen  and  nitrous 
oxide,  there  is  almost  an  entire  absence  of  cyanosis,  stertor  or 
jactitation,  which  are  the  characteristic  symptoms  of  asphyxia. 
It  is  this  fact  which  proves  our  theory  that  nitrous  oxide  pos- 
sesses anaesthetic  properties  apart  from  those  which  it  induces 
by  virtue  of  its  shutting  off  of  oxygen.  According  to  Jol3'et 
and  Blanche,  coma  is  not  produced  until  the  amount  of  oxygen 
in  the  blood  is  reduced  to  between  three  and  four  per  cent. 
When  so  reduced,  we  have  cyanosis  as  a  concomitant. 

The  absence  of  duskiness  of  the  features  may  be  relied  upon 
as  an  indication  that  there  is  certainly  a  greater  amount  of  oxy- 


DR.  Hewitt's  method  of  using  nitrous  oxide.      101 

gen  than  four  per  cent,  present.  M.  Claude  Martin,  of  Lj'on-s, 
administered  to  a  dog  a  mixture  of  nitrous  oxide  with  fifteen 
per  cent,  of  oxygen  for  three  consecutive  da3's,  with  apparently 
no  ill  eflfects  upon  the  animal.  "  It  must  be  evident,  then,  that 
we  have  to  deal,  in  the  case  of  the  mixed  gases,  with  an  anaes- 
thetic which  does  not  induce  asphyxia ;  or,  if  so,  the  condition 
is  modified  to  an  extent  which  obliterates  its  ordinary  character- 
istic symptoms.  It  is  also  evident,  for  this  reason,  that  it  pos- 
sesses greater  freedom  from  danger.  If  it  can  be  demonstrated 
that  the  anesthesia  induced  by  the  mixture  of  nitrous  oxide 
and  oxj'^gen,  is  nevertheless  caused  by  the  action  of  insufficiently 
oxygenated  blood  upon  the  nerve  centres,  notwithstanding  the 
entire  absence  of  all  of  the  usual  symptoms  of  oxj-gen-starva- 
tion,  we  may  strongly  suspect  that  other  well-known  anaesthetics 
act  in  an  analogous  way,  by  interfering  with  proper  oxygenation 
of  the  blood."  ' 

On  Dr.  Hewitt's  3Ietliod  of  Using-  Xitrous  Oxide 
and  Oxj'gen  as  an  An^estlietie. 

The  views  which  have  been  published  in  this  country  have 
been,  in  the  main,  favorable  to  the  employment  of  Dr.  Hewitt's 
method  in  dental  operations  and  minor  surgery.  The  following 
was  the  time  consumed  by  this  method  in  the  case  of  two  pa- 
tients, Dr.  J.  D.  Thomas  performing  the  operation  for  the  re- 
moval of  carious  teeth.  In  the  first  case,  one  hundred  and  ten 
seconds  were  consumed  before  the  corneal  reflexes  were  fully 
abolished,  and,  as  nearly  as  could  be  determined,  there  re- 
mained forty  seconds  of  available  anaesthesia  after  removal  of 
the  face-piece. 

In  the  second  case,  one  hundred  and  sixty  seconds  were  con- 
sumed in  the  administration,  resulting  in  thirty  seconds  of  avail- 
able anaesthesia.  In  the  pulse,  as  reported,  at  the  close  of  the 
administration  there  was  found  but  slight  variation  either  in 
fulness  or  frequency.  There  were  none  of  the  usual  sjTnptoms 
of  asphyxia  manifested,  there  being  an  entire  absence  of  blue- 
ness,  stertor  or  jactitation.  Dr.  Thomas  objects  to  the  face- 
piece  of  Dr.  Hewitt,  as  he  desires  at  all  times  to  see  the  patient's 
lips. 


102  ARTIFICIAL    ANESTHESIA. 

Dr.  Kirk,*  who  read  a  valuable  pai)er  on  the  subject  of  Dr. 
Hewitt's  method  from  personal  observation,  made  the  following 
remarks  at  the  conclusion  of  the  discussion  : 

"I  want  to  correct  one  idea  of  Dr.  Thomas  that  is  erro- 
neous, namely,  that  the  time  of  administering  the  mixed  gases 
is  in  any  sense  a  guide  to  the  condition.  We  were  simply 
timing  the  administration  as  a  matter  of  record,  and  not  as  a 
guide  for  the  anaesthetic  condition  produced. 

"There  is  another  point  to  be  borne  in  mind  in  relation  to  the 
face-piece  as  used  in  this  method.  By  Dr.  Hewitt's  method 
you  are  giving  oxygen  in  connection  with  the  nitrous  oxide 
almost  from  the  start,  and  the  patient  is  getting  a  certain 
amount  of  oxj^gen  immediately.  There  is  no  time  when  the 
patient  is  not  taking  some  oxygen.  Consequently,  the  chances 
of  oxygen-starvation  are  very  much  lessened,  the  asphyxial 
condition  to  which  Dr.  Thomas  alludes  being  constantly  pre- 
vented, and  we  thus  eliminate  what  is  a  very  potent  element  of 
danger  in  giving  nitrous  oxide  alone. 

"I  quite  agree  with  him  as  to  the  danger  of  proceeding  with 
the  administration  where  the  patient  so  quickly  succumbs  and 
becomes  cyanotic  under  pure  gas.  There  the  face-piece,  I  ad- 
mit, is  a  serious  objection,  but  in  the  method  of  Dr.  Hewitt  the 
fact  that  we  are  giving  oxygen  continuously  with  the  nitrous 
oxide  is  a  safeguard  against  any  accident  which  may  occur  from 
the  inability  to  see  the  lips." 

Conclusions  of  Dr.  Hewitt. 

"So  far  as  my  experience  has  gone,  I  am  inclined  to  regard 
the  use  of  oxygen  with  nitrous  oxide  as  of  distinct  advantage  in 
the  large  majority  of  cases  in  dental  practice.  But  we  cannot 
shut  our  eyes  to  the  fact  that  the  administration  of  the  mixed 
gases  involves  more  time,  more  attention  to  detail,  and  more 
skill  than  are  essential  for  the  employment  of  nitrous  oxide  in 
the  ordinary  manner,  whilst  the  risks  of  unpleasant  after-effects 

*  Dental  Cosmos,  Dec,  1894,  op.  cit.  Experiments  made  with  Prof. 
Dow  and  Dr.  M.  H.  Cryer.  Dr.  Kirk,  editor  of  the  Dental  Cosmos, 
meeting  of  Academy  of  Stomatology. 


CONCLUSIONS    OF    DR.    HEWITT.  103 

are  a  trifle  greater.  It  hence  follows,  that  unless  we  can  show 
that  the  gain  is  considerable  we  are  hardly  justified  in  advocat- 
ing an}'  departure  from  the  usual  lines  of  practice,  I  have 
attempted  to  point  out  that  in  many  instances  this  gain  is  con- 
siderable, and  for  my  own  part  I  shall  certainly  continue  to  use 
the  mixture  in  preference  to  ordinary  nitrous  oxide  for  such 
cases.  But  when  a  very  short  operation  has  to  be  performed 
upon  a  patient  who  has  taken  nitrous  oxide  itself  on  a  pre- 
vious occasion  with  the  best  results,  I  would  continue  to  use  it." 

When  any  additional  preparation  might  alarm  a  nervous  sub- 
ject, or  when  time  is  a  matter  of  great  consideration,  the  use  of 
nitrous  oxide  per  se  is  possibly  preferable  to  that  of  the  mixture. 
I  need  hardly  remind,  you  that  it  is  not  always  an  easy  matter  to 
prophesy  the  duration  of  an  operation.  A  tooth  which  is 
looked  upon  as  easy  of  removal  often  gives  trouble,  and  under 
these  circumstances  an  additional  fifteen  or  twenty  seconds  in 
the  anaesthesia  may  make  all  the  difference  in  the  result  of  the 
case. 

By  the  use  of  the  apparatus  brought  before  your  notice,  an 
attempt  may  be  made  in  every  case  to  secure  the  satisfactory 
form  of  anaesthesia  which  has  been  described.  Should  the  case 
turn  out  to  be  an  exceptional  one,  nitrous  oxide  alone  can  at 
once  be  substituted  with  the  best  results.  In  this  way  every 
case  may  be  brought  to  a  successful  issue.  The  extra  trouble 
incurred  by  having  a  bag  full  of  oxygen  in  communication  with 
the  ordinary  nitrous  oxide  apparatus  is  very  small,  whilst  the 
benefits  that  will  result  in  the  majority  of  cases  from  the  addi- 
tion of  a  proper  proportion  of  this  gas  are  very  great. 

The  mixture  is  to  be  chiefly  recommended  as  preferable  to 
nitrous  oxide  itself — 

(1)  In  children  ; 

(2)  In  anaemic  and  debilitated  patients  ; 

(3)  In  any  one  who  has  previously  exhibited  great  unsuscep- 
tibility  to  nitrous  oxide,  and  has  remained  a  very  short  time 
under  the  influence  of  the  gas ; 

(4)  In  patients  who,  under  nitrous  oxide  itself,  have  experi- 
enced unpleasant  sensations ; 

(5)  In  patients  very  advanced  in  j^ears,  and  in  those  suffering 


104  ARTIFICIAL    ANESTHESIA. 

from  such  serious  visceral  disease  that  ordinary  nitrous  oxide 
seems  unadvisable.* 

Observations  on  the  Stateiiieiits  and  Abstracts  from 
Monograph  of  Dr.  H.  C.  Wood.f 

Experimental  Study  of  Nitrous  Oxide. 

The  length  of  time  which  Drs.  Wood  and  D.  Cerna  found  to 
elapse  between  the  commencement  of  inhalation  and  anaesthe- 
sia, varied  from  fifty-one  seconds  to  three  minutes  and  fifty 
seconds.  The  average  period,  two  minutes  and  eight  seconds. 
This  is  the  same  as  given  in  our  manual,  p.  92,  one  minute 
fifty-five  seconds  ;  never  less  than  one  minute  forty-nine  sec- 
onds. Pulse  experiment,  1.  The  inhalation  of  nitrous  oxide 
was  immediately  followed  by  an  enormous  rise  of  arterial  pres- 
sure, associated  with  great  disturbance  of  the  pulse ;  the  heart 
beats  very  irregular,  with  long  pauses,  followed  by  a  number  of 
very  rapid  pulse  beats.  Compare  these  with  the  tracings  at 
p.  91,  on  man  in  our  work.  This  increase  of  the  pulse  in  man 
is  sometimes  due  to  excitement  resulting  from  fear.  As  soon 
as  the  inhalation  is  free  and  full,  respiration  becomes  slow,  the 
tension  of  the  pulse  falls,  the  number  of  beats  per  minute  is  in- 
creased, the  tidal  or  predicrotic  wave  is  slightly  better  marked, 
and  the  dicrotic  wave  becomes  well  marked.  When  the  mouth- 
piece is  removed,  and  any  operation  is  to  be  performed,  the 
pulse  undergoes  a  marked  change.  This  is  probably  due  to  re- 
flex action  through  the  vagus  to  the  heart.  Immediately  after 
the  operation  the  pulse  gradually  assumes  its  normal  condition 
(in  the  reverse  order)  through  the  stages  it  had  undergone 
when  the  nitrous  oxide  gas  was  applied. 

Experiment  4  shows  the  pulse  so  characteristic  of  the  action 
of  nitrous  oxide  gas.  When  the  pneumogastric  had  been  pre- 
viously divided  it  is  absent,  and  it  is  therefore  due  to  stimula- 
tion of  the  inhibitory  cardiac  apparatus.     This  is  the  same  idea, 

*  Pamphlet  received  from  Dr.  Hewitt. 

t  Presented  to  the  Interoational  Congress,  Berlin,  August  6,  1890, 
with  the  experiments  with  Dr.  D.  Cerna  (The  Therapeutic  Gazette, 
August,  1890). 


EXPERIMENTS    OF    DR.  WOOD.  105 

only  in  different  language,  as  is  our  work.  The  extraordinary 
rise  in  arterial  pressure  which  took  place  in  some  of  Dr.  Wood's 
experiments  during  the  inhalation  of  nitrous  oxide  gas,  has, 
as  he  observes,  an  important  bearing  upon  practical  medi- 
cine. 

Some  time  since  a  death  from  apoplexy  occurred  in  Philadel- 
phia* directly  after  the  inhalation  of  nitrous  oxide,  and  it  is 
well  known  that  Dr.  Lafont,  of  France,  has  asserted  that  occa- 
sionally diabetes  mellitus  and  albuminuria,  have  been  produced 
by  the  anaesthetic  use  of  nitrous  oxide.  It  is  entirely  conceiv- 
able that  in  a  man  with  atheromatous  or  otherwise  diseased  ar- 
teries the  inhalation  of  the  gas  might  cause  a  rise  in  the  arte- 
rial pressure,  which  should  produce  rupture  of  smaller  or  larger 
vessels,  and  cause  serious  sj^mptoms. 

Chloroform  directly  depresses  the  heart,  and  even  ether  has  a 
similar  influence  when  it  is  in  excess,  but  nitrous  oxide  would 
appear  directly  or  indirectly,  to  stimulate  the  heart  and  to  keep 
up  this  stimulation,  at  a  time  when  the  respiratory  function  is 
almost  completely  obliterated. 

Expeilinents  with  Nitrous  Oxide  Gas  and  Mtrogen 

Gas. 

"A  lost  respiratory  function  can  be  temporarily  replaced  by 
artificial  respiration,  but  no  substitute  has  been  found  at  all  for 
an  arrested  heart.  It  is  easy  to  see  why  death  has  so  very 
rarely  occurred  during  anaesthesia  from  nitrous  oxide.  Dr. 
Wood  comes  to  the  conclusion  by  experiment  '  that  the  fall  of 
arterial  pressure  which  occurs  in  the  advanced  stage  of  nitrous 
oxide  anaesthesia,  is  due  to  vaso-motor  paralysis.'  The  same 
danger,  according  to  the  Hyderabad  Commission,  is  to  be  found 
in  chloroform,  viz.,  paralj^sis  of  the  vaso-motor  centre.  Nitro- 
gen gas  also  received  the  attention  of  Drs.  Wood  and  Cerna. 
The  experiments  were  three  in  number,  f  In  the  first,  uncon- 
sciousness was  complete  in  one  minute  and  ten  seconds.     Death 

*  See  details  of  case,  Manual  of  Ansesthetics,  p.  115 ;  also  influence 
of  Nitrous  Oxide  on  Brain  and  Spinal  Cord,  p.  18 ;  and  also  a  recent 
report  of  deaths. 

t  Therap.  Gaz.,  1890. 

8 


106  ARTIFICIAL    ANAESTHESIA. 

occurred  three  minutes  after  the  beginning  of  the  inhalation  of 
the  gas;  the  arterial  pressure  was  raised  in  forty  seconds 
twelve  millimetres  ;  during  the  next  ten  seconds  it  went  up  ten 
millimetres  more,  and  then  fell  abruptly  eighty  to  ninety  milli- 
metres in  the  next  ten  seconds,  and  continued  to  fall  until  death 
took  place.  The  other  two  were  similar,  as  may  be  seen  by  the 
table.  The  experiments,  according  to  the  doctor,  indicate  a 
parity  of  action  between  nitrogen  and  nitrous  oxide,  that  the 
two  agents  act  in  a  similar  manner,  that  is,  by  shutting  off 
oxygen. ' ' 

Oxygen  and  Carbonic  Acid. 

"In  the  second  series  of  these  experiments  was  determined 
the  action  of  oxygen  and  carbonic  acid.  In  the  first  of  these  ex- 
periments, after  the  inhalation  of  pure  oxygen  for  two  minutes, 
the  pulse  was  four  beats  per  minute  below  its  starting-point, 
and  the  arterial  pressure  three  millimetres  below  its  level.  Ex- 
periment 13,  the  pulse  at  the  end  of  four  minutes  of  inhalation 
had  been  reduced  eight  beats,  while  the  blood  pressure  had 
fallen  four  millimetres ;  in  the  third  experiment  about  the 
same. 

"These  experiments  certainly  show  that  the  inhalation  of 
pure  oxygen  gas  has  no  influence  upon  the  circulation — a  simple 
pumping  out  of  the  blood  of  carbonic  acid.  Then  followed  a 
direct  experimental  study  of  the  effects  of  carbonic  acid,  pure 
and  dilute  with  air,  upon  arterial  pressure. 

"As  a  result  of  the  experiments,  Dr.  Wood  thinks  that  the 
following  proposition  is  established  :  carbonic  acid,  when 
breathed  into  the  lungs  alone,  sometimes  causes  a  slight  and 
temporary  rise  in  the  arterial  pressure,  but  usually  after  a  short 
time  a  very  decided  fall,  having  the  most  power  when  mixed 
with  oxygen  in  the  proportion  of  two  to  one.  It  also  acts 
as  a  powerful  pulse  depressor.  After  section  of  the  vagi, 
the  inhalation  of  carbonic  acid  does  not  produce  slowing  of  the 
pulse. ' ' 

The  observations  and  experiments  on  oxygen  of  Dr.  Wood 
differ  from  our  own  and  many  others,  as  we  will  be  able  to  show 
under  oxygen. 


THE    AFTER-EFFECTS    OF    NITROUS    OXIDE    GAS.       107 

The  After-Eifects  of  Nitrous  Oxide  Gas. 

Many  persons  will  remember  that  both  Dr.  Barker  and  the 
late  Dr.  Webb,  while  living,  declared  that  thej'  felt  some  ill 
effects  in  their  own  persons  ^rom  nitrous  oxide  gas. 

No  one  can  read  the  full  account  which  we  liave  given  of  the 
ph^'siological  action  of  this  gas  upon  the  nervous  sj'Stem,  more 
especially  the  brain  and  spinal  cord,  without  perceiving  the 
powerful  impressions  which  it  makes  upon  these  important 
organs,  and  how  near  unto  death  it  may  bring  the  patient.  In 
our  own  experiments  and  those  of  Dr.  Buxton  on  the  brain  and 
spinal  cord,  we  have  met  with  dilatation  and  laceration  of  the 
vessels,  with  of  course  an  increased  impulse  in  the  blood  supply 
to  the  nerve  centres  and  vessels. 

Such  a  state  would  indicate  a  condition  favorable  to  nervous 
energy,  but  this  is  soon  followed  by  interference  with  the  due 
regularity  of  the  cerebral  and  cerebellum  circulation,  if  carried 
too  far,  producing  irregular  muscular  action,  rigidity  and  ner- 
vous exhaustion  ;  also  disturbance  producing  marked  reflex 
action  and  even  ankle  clonus.  Amongst  the  occasional  phe- 
nomena which  occur  are  opisthotonus,  paralysis  of  the  bladder 
and  involuntary  action  of  the  urinary  and  rectal  secretions. 

Another  distressing  class  of  symptoms  are  the  excitation  of 
the  sexual  centres  and  abolition  of  the  normal  checks  imposed 
upon  the  production  of  orgasm. 

In  some  cases  there  is  a  quiet  prolongation  of  nitrous  oxide 
narcosis,  unaccompanied  by  the  wild  convulsions  of  asphyxia, 
when  the  breathing  absolutely  stops  while  the  heart  beats  on. 

Fortunatel}',  in  these  cases,  artificial  respiration,  conducted 
for  one  or  two  admissions  of  air,  restores  the  patient  to  anima- 
tion, and  all  goes  well. 

No  danger  is,  in  fact  incurred,  unless  the  anaesthetist  is  in- 
competent or  negligent  of  his  solemn  charge. 

The  following  observations  expressed  in  a  recent  discussion 
on  the  subject  are  of  value  : 

"Dr.  J.  D.  Thomas  recognized  ten  or  twelve  5"ears  ago  the 
dangerous  element  of  asphyxia  in  giving  nitrous  oxide,  and  it 
came  in  this  way.  In  operations  requiring  considerable  time  it 
was  considered  dangerous  to  continue  the  inhalation  long,  but 


108  ARTIFICIAL    ANESTHESIA. 

by  alternating  a  breath  of  air  with  a  breath  of  gas  it  seemed 
to  overcome  all  dangerous  symptoms  which  accompany  the 
asphyxiated  condition  from  the  use  of  pure  nitrous  oxide. 
Even  in  that  class  of  persons  who  asphyxiate  very  easily,  show- 
ing oxygen-starvation  which  begins  as  soon  as  the  jSrst  or  second 
breath  is  taken,  the  admission  of  a  little  atmospheric  oxygen 
will  relieve  it,  so  that  has  been  the  method  which  I  have  fol- 
lowed for  ten  or  twelve  years  in  certain  cases,  but  not  in  all. 

"In  giving  nitrous  oxide,  the  only  danger  accompanying  it,  in 
my  mind,  is  the  want  of  oxygen.  That  is  exhibited  in  numer- 
ous ways.  All  the  deaths  that  have  occurred,  when  not  by 
accident,  and  which  have  resulted  from  the  physiological  action 
of  nitrous  oxide,  have  been,  to  my  mind,  from  the  want  of 
oxygen. 

"As  to  accidents,  many  things  might  occur.  Among  others, 
the  one  where  there  is  considerable  jactitation  producing  con- 
striction of  the  glottis.  This  is  the  result  of  asphyxiation,  and 
one  breath  of  air  will  relieve  it  entirely.  Yet  the  glottis  may 
be  so  constricted  as  to  produce  actual  suffocation  ;  one  or  two 
have  died  in  that  way.  That  is,  in  my  judgment,  an  accident, 
for  as  soon  as  the  patient  gets  a  breath  of  air  he  is  safe.  If  the 
trachea  had  been  opened  below  the  larynx  it  would  have  been 
obviated. 

"Another  phase  of  the  want  of  oxygen  is  that  shown  in  the 
respiration  of  people  who  breathe  very  slowly  and  who  never 
oxygenate  the  blood  to  the  proper  degree  in  normal  respiration, 
and  who  thus  never  get  a  full  supply  of  oxygen.  The  moment 
it  is  reduced  or  cut  off  they  immediately  show  an  asphyxiated 
condition,  and  sometimes  very  quickly  a  suspension  of  breath- 
ing, which  is  perhaps  the  first  exhibition  of  danger.  Most  of 
the  deaths  have  been  shown  to  have  been  by  suspended  respi- 
ration, the  heart's  action  continuing  some  time  afterward,  some- 
times ten  or  eleven  minutes. 

"  Now  there  is  the  other  extreme,  the  class  of  anaemic  people ; 
their  blood  is  lacking  in  red  corpuscles  to  such  an  extent  that 
the  lips  show  no  color  at  all.  I  have  seen  cases  of  this  anaemic 
character  which  will  often  succumb,  after  taking  the  second 
breath  of  nitrous  oxide,  before  any  effect  could  possibly  have 


ACCIDENTS    IN    EXTRACTING    TEETH.  109 

been  made  on  the  nerve  centres  directly  by  the  gas.  It  is  not 
the  effect  of  the  an<iesthetic,  but  simply  want  of  oxygen,  a 
starvation  of  the  nerves  that  control  the  action  of  the  heart. 

"These  are  two  conditions  which,  to  my  mind,  are  dangerous 
ones  in  giving  nitrous  oxide. 

"With  the  extremelj'^  anj«mic,  by  the  admission  of  air  we  can 
obviate  the  asphyxial  condition,  so  that  they  can  be  carried  to  a 
state  of  unconsciousness  without  any  of  those  symptoms  occur- 
ring. Again,  the  extremely  florid  show  the  effects  of  asphyxia 
very  readil,y,  simply  because  they  demand  all  the  oxj^gen  that  the 
lungs  will  supply  to  aerate  their  blood  sufficiently ;  when  you 
cut  ofi"  any  of  it,  the  blue  appearance  will  take  place  almost 
immediately^,  with  the  second  or  third  breath.  If  you  con- 
tinue, without  the  admission  of  oxj^gen,  they  will  discolor  and 
be  affected  to  such  an  extent  as  to  go  into  convulsions,  not  onl}'^ 
jactitation,  but  absolute  convulsions.  I  have  seen  that  take 
place." 

The  inhalation  of  nitrous  oxide  gas,  long  continued,  causes 
progressive  depression  of  the  vital  functions,  which,  like  all 
sj'^stematic  anassthetics,  tends  to  death.  This  must  never  be  for- 
gotten. 

Accidents  in  Extracting"  Teeth  under  Xitrous  Oxide. 

Dr.  Buxton  gives  some  important  hints  in  extracting  teeth 
while  under  the  influence  of  nitrous  oxide  gas.  ' '  The  mouth 
should  be  cleared  of  artificial  dentures,  especiallj^  small  plates. 
Accidents  have  arisen  from  teeth,  or  portions  of  teeth,  being 
allowed  to  fall  from  the  beaks  of  forceps  back  over  the  glottis, 
a  deep  inspiration  then  drawing  the  tooth  into  the  trachea.  The 
tooth  forceps  have,  in  recorded  cases,  broken  and  a  fragment 
become  lodged  in  the  trachea.  All  instruments  used  for  the 
mouth  should  be  carefully  examined  for  flaws,  and  all  gags, 
props,  etc.,  should  be  secured  b}^  fishing  gut  or  some  strong, 
cleanly  material  and  attached  outside  the  mouth. 

"  In  extracting  teeth,  the  forceps  after  each  extraction  should 
be  wiped  tidce,  as  taught  by  Clover,  before  attacking  another 
tooth.     Fragments  of  teeth  should  never  be  left  in  the  mouth, 


110  ARTIFICIAL    ANAESTHESIA. 

even  with  the  object  of  gaining  time  ;  each  fragment  should 
be  removed  before  any  further  proceedings  by  bending  the 
head  forward  and  sweeping  the  finger  around  the  mouth.  The 
tongue  must  not  be  drawn  forward,  as  by  so  doing  the  larynx 
will  be  left  exposed,  the  epiglottis  being  dragged  from  it, 
while  the  patient  is  thereby  induced  to  take  a  deep  inspira- 
tion, which  will  probably  cause  the  foreign  body  to  enter  the  air 
passage. ' ' 

In  its  pure  state  the  gas  may  be  given  to  almost  any  one,  if 
judiciously  administered. 

Among  the  difficulties  which  may  be  met  with  as  having  the 
appearance  of  danger  in  administering  nitrous  oxide,  the  most 
common  is  constriction  or  spasm  of  the  glottis,  or  swallowing 
the  tongue.  The  use  of  the  prop  cannot  be  over-estimated  in 
such  cases.  The  patient  becomes  very  dark  in  the  face  ;  there 
is  a  violent  exertion  of  the  diaphragm,  and  he  presents  every 
indication  of  approaching  asphyxia,  which,  by  having  the  mouth 
well  propped  open,  is  very  readily  relieved  by  catching  hold  of 
the  tongue  with  a  dry  napkin  and  pulling  it  out  of  the  mouth, 
and  at  the  same  time  raising  the  body  forward.  As  soon  as  the 
patient  has  taken  two  or  three  inspirations  of  pure  air  the  ten- 
sion is  relaxed,  and  recovery  will  take  place.  Another  formid- 
able symptom  of  danger  is  when  your  patient  is  attacked  with 
syncope  while  under  the  influence  of  the  gas.  Be  sure  the  air 
passages  are  open  by  pulling  the  tongue  forward.  Then,  the 
patient  being  in  a  sitting  posture,  bring  the  head  and  body  for- 
ward with  considerable  violence,  which  will  generally  prove 
sufficient.  You  may,  however,  meet  cases  which  will  require 
more  effective  remedies.  The  object  is  first  to  get  the  head  on 
a  level  with  or  below  the  heart,  so  the  blood  may  flow  freely  to 
the  brain,  which  is  done  by  laying  the  patient  on  the  floor  ; 
then  throw  cold  water  violently  in  the  face.  The  most  effectual 
remedy  is  to  place  the  finger  far  down  the  throat,  which  will 
produce  involuntary  retching,  and  is  the  most  efficient  action  to 
bring  about  restoration,  after  which  treat  the  patient  as  in  any 
ordinary  case  of  fainting,  giving  a  little  brandy,  ammoniated 
tincture  of  valerian  or  aromatic  spirits  of  ammonia,  ten  to 
twenty-drop  doses  in  water,  and  allowing  the  patient  to  lie  on 


ADMINISTERING  NITROUS  OXIDE  TO  CHILDREN.        Ill 

the  lounge  until  strong  enough  to  walk  in  the  fresh  air,  when 
he  or  she  will  soon  recover  completely. 

In  the  hands  of  a  skilful  and  careful  operator  no  great  risk 
attends  the  employment  of  this  anaesthetic,  but  those  who  are 
less  skilful,  and  are  inexperienced,  should  reject  cases  of 
great  physical  exhaustion,  or  patients  with  a  feeble  or  fatty 
heart,  indicated  by  pain  and  flushed  face.  The  distension  of 
the  right  cavities,  which  accompanies  the  disappearance  of  the 
radial  pulse,  and  the  general  lividity  of  the  features,  may  be 
attended  with  some  degree  of  risk,  and  the  danger  is  increased 
when,  the  muscles  of  the  trunk  and  limbs  being  convulsed,  the 
pressure  of  the  contracting  muscles  upon  the  .veins  drives  the 
blood  forcibly  towards  the  right  cavities  of  the  heart,  and  so 
adds  to  their  distension. 

Adniinisteriiig-  Nitrous  Oxide  to  Children. 

Dr.  Buxton  states,  that  in  giving  nitrous  oxide  to  children, 
the  face-piece  (not  so  much  emploj^ed  in  this  country)  should 
be  removed  with  the  first  sign  of  jactitation  ;  otherwise,  these 
small  bodies  become  so  convulsed  that  it  is  difficult  to  keep  them 
still  for  operation,  and  much  valuable  time  is  lost  in  the  attempt 
to  place  them  in  a  convenient  position. 

In  the  administration  of  nitrous  oxide  gas  it  is  absolutely 
necessary  that  the  operator  should  possess  a  thorough  knowl- 
edge of  phj'siology,  so  as  to  be  able  to  examine  beforehand,  and 
with  great  care,  the  heart,  the  lungs,  and  the  kidneys  of  the 
patient  to  be  anaesthetized. 

Considering  that  of  all  surgical  operations,  the  extraction  of 
a  tooth  may  be  looked  upon  as  an  operation  usually  of  slight 
importance,  and  which  only  requires  some  dexterity  of  hand, 
and  may  thus  be  performed  by  any  dentist,  the  case  is  not  the 
same  when  performed  during  anaesthesia — that  in  the  latter 
case,  according  to  the  opinion  of  experts,  it  belongs  incontest- 
ably  to  the  class  of  niojor  operations.  Under  these  circum- 
stances, according  to  the  provisions  of  Article  29  of  the  Law  of 
Ventore,  XI.,  Officiers  de  Sante  of  France,  and  with  still  more 
reason,  dentists  who  hold  no  diploma  have  no  right  to  perform 
it,  except  under  the  superintendence  of  a  doctor. 


112  ARTIFICIAL    ANAESTHESIA. 

Annexed  are  the  views  oF  Dr.  Th.  David,  director  of  the 
Ecole  Dentaire  of  Paris,  on  this  subject,  who  has  come  to  the 
following  conclusions : 

1.  The  extraction  of  a  tooth  of  a  person  under  anaesthesia  is 
to  be  looked  upon  as  one  of  the  major  surgical  operations 
which,  by  the  terms  of  the  law  of  Ventore,  are  onl}^  to  be  per- 
formed by  doctors  of  medicine. 

2.  Officiers  de  Sante  are  only  entitled  to  administer  anaes- 
thetics under  the  guidance  and  in  the  presence  of  a  doctor  of 
medicine. 

3.  No  one  can  pretend  that  an  operation  which  even  Ofl&ciers 
de  Sante  are  not, allowed  to  perform  can  be  considered  to  form 
part  of  the  practice  of  the  dental  art,  and  be  permitted  to 
people  who  possess  no  medical  qualification  of  any  kind. 

4.  Dentists  who  do  not  hold  a  diploma  and  who  administer 
anaesthetics  alone  incur  the  penalties  edicted  against  the  illegal 
practice  of  medicine  (Arts.  35  and  36  of  the  law  of  Ventore  au 
XL),  and  in  the  event  of  an  accident,  the  penalties  edicted  by 
Article  319,  of  the  Code  Penal,  for  accidental  homicide  (homi- 
cide par  imprudence). 

Deaths  Under  Nitrous  Oxide  Gas. 

The  following  deaths  have  occurred  since  the  seven  recorded 
in  the  publication  of  our  third  edition.*  The  facts  as  reported 
are  that  in  London,  England,  Mr.  Lee,  aged  25,  a  man  in  ordi- 
nary health,  died  in  a  dentist's  chair  after  the  extraction  of  a 
tooth  for  which  nitrous  oxide  had  been  given.  Mx-  Lee  entered 
a  dentist's  surgery  and  complained  of  toothache.  A  neighbor- 
ing medical  practitioner  was  called  in,  nitrous  oxide  gas  was 
administered,  the  patient  went  under  its  influence  without  any- 
thing unusual  taking  place,  and  the  tooth  was  extracted.  Sub- 
sequently the  breathing  became  "heavy,"  and  finally  ceased. 
The  patient  was  placed   supine  upon  the  floor  and  artificial 

*  The  Lancet  Commission  has  collected  seventeen  deaths  as  having 
occurred  during  the  anaesthetic  use  of  the  gas.  Dr.  Charles  M. 
Buchanan  has  stated  the  mortality  of  nitrous  oxide  inhalation  is 
2  into  10,500,000.— Medical  News,  Vol.  Ixii.,  April,  1893. 


DIED    IN    A    dentist's    CHAIR.  113 

respiration  was  attempted.  It  is  stated  that  "the  throat 
became  so  swollen  that  the  mouth  could  not  be  closed,"  and 
tracheotomy  was  performed,  artificial  respiration  being  practiced 
for  half  an  hour.  The  patient,  however,  never  recovered.  The 
gentleman  who  gave  the  gas  is  reported  to  have  said  that  he 
had  had  an  experience  of  between  30,000  and  40,000  cases 
without  a  previous  accident.  He  further  stated  that  he  had 
tried  the  use  of  ether  and  nitrite  of  amyl,  which,  being  cardiac 
stimulants,  would  point  to  there  having  been  some  symptoms 
of  circulatory  failure.  Whether  death  was  purely  asphyxial, 
as  the  verdict  averred,  or  not,  we  cannot  upon  this  evidence 
decide.  The  necropsy  was  said  to  have  revealed  that  the 
wind-pipe  was  filled  with  mucus — a  fact  which  points  rather  to 
some  irritant  being  at  work.  Impure  nitrous  oxide  is  a  power- 
ful irritant,  from  the  presence  in  it  of  higher  oxides  of  nitrogen, 
and  could  have  produced  this  result.  We  are  not  told  whether 
the  patient  had  just  partaken  of  luncheon  and  vomited,  nor  was 
any  statement  made  as  to  whether  the  gas  itself  was  properly 
prepared  and  had  been  used  safely  with  other  patients.  Casual- 
ties, which  probably  can  be  counted  on  the  fingers  out  of  many 
millions  of  administrations  of  nitrous  oxide  gas,  have  been  due 
to  shock,  spasm  of  the  larynx,  impaction  of  foreign  bodies  in 
the  air  passages  —  e.^. ,  blood  clot  and  mucus,  fragments  of 
teeth,  etc. — or  syncope.  To  which  of  these  classes  the  lament- 
able death  of  Mr.  Lee  belongs  it  is  impossible  for  us  to  say. 
Recently  a  death  occurred  while  the  patient  was  awaiting  the 
turn  to  have  the  gas,  and  no  doubt  fear  is  a  potent  element  in 
many  deaths  put  down  to  an  angesthetic.  It  has  to  be  remem- 
bered that  so  enormous  is  the  use  of  this  anaesthetic  at  the 
present  time  that  with  care  and  skill  the  risks  its  use  entails 
may,  even  in  the  face  of  such  sad  occurrences  as  the  one  of 
which  we  have  been  speaking,  be  taken  as  infinitely  small. — 
London  Lancet.  March  3,  1894. 

Died  iu  a  Dentist's  Chair. 

Buifalo,  May  1,  1892.— Mrs.  Elizabeth  Lipp,  a  handsome 
j'Oung  woman  of  Clinton  street,  died  in  a  dentist's  chair  Satur- 
da}^  night  while  under  the  influence  of  laughing  gas.     Accom- 


114  ARTIFICIAL    ANAESTHESIA. 

panied  by  her  husband,  she  went  to  the  office  of  Dr.  E.  C. 
Longnecter,  early  in  the  evening,  to  have  four  teeth  extracted. 
The  dentist  advised  the  use  of  gas,  and  Mrs.  Lipp  consented. 
She  did  not  yield  readily  to  its  influence,  and  the  usual  dose 
was  increased.  She  immediately  fell  into  an  unconscious  state. 
After  three  teeth  had  been  extracted  the  husband  grew  fright- 
ened at  the  appearance  of  his  wife.  Her  face  had  become 
pallid,  her  breathing  was  light,  and  no  pulse  could  be  found. 
"  My  God,  she's  dead,"  cried  the  husband  as  he  seized  her 
hands  and  covered  them  with  kisses. 

The  dentist  assured  him  that  she  was  all  right  and  then  drew 
the  fourth  tooth.  When  he  endeavored  to  restore  the  woman 
to  consciousness  he  was  horrified  that  every  effort  failed.  Her 
husband  hurried  for  a  physician,  but  just  as  the  doctor  entered 
the  room  the  woman  died.  She  had  been  in  the  chair  only  ten 
minutes.  Coroner  Ransom  will  hold  an  inquest,  and  it  is  likely 
that  Dr.  Longnecter  may  have  to  answer  to  a  jury  for  criminal 
carelessness.  Mrs.  Lipp  was  the  mother  of  two  children,  and 
had  been  married  but  five  years.  Her  husband  is  prostrated 
with  grief,  and  it  is  feared  he  may  lose  his  reason, 

Deatli  from  Nitrous  Oxide. 

A  death  from  nitrous  oxide  is  reported  from  Montreal.  A 
man,  aged  24,  went  to  the  office  of  a  dentist  to  have  a  tooth 
extracted,  and  requested  to  have  gas  administered.  After  as- 
suring himself  that  the  patient  was  not  suffering  from  heart  or 
lung  disease,  the  doctor  administered  the  gas.  No  sooner  had 
the  tooth  been  extracted  than  the  patient  gave  a  gasp  and  fell 
over  in  the  chair.  He  was  placed  on  the  floor  and  artificial  res- 
piration performed,  but  without  restoring  animation.  The  pa- 
tient was  not  under  the  influence  of  liquor,  and  five  hours  had 
elapsed  since  last  taking  food  (breakfast).  The  purity  of  the 
gas  was  tested  shortly  after  the  accident  by  the  President  of  the 
Dental  Association,  Dr.  Beers,  who  himself  inhaled  it  from  the 
same  inhaler.  The  verdict  of  the  jury  was  that  the  mati  died 
from  syncope,  caused  by  the  administration  of  gas,  and  they  ex- 
onerated the  dentist  from  blame. — Druggists'  Circular,  Sep- 
tember, 1890. 


DEATHS    FROM    NITROUS    OXIDE    GAS.  115 

Death  from  Nitrous  Oxide. 

W.  P.  ;  residence  Chestnut  Hill.  Had  been  for  some  time 
suffering  from  the  effects  of  the  grippe.  His  physician,  Dr.  M., 
had  done  all  he  could  for  him  on  account  of  the  intense  pain  in 
the  head.  Dr.  Wm.  W.  was  called  in  consultation,  and  discov- 
ered a  diseased  tooth,  and  thought  its  removal  would  perhaps 
reheve  the  pain.  Accordinglj^  Dr.  K.  was  sent  for,  and  admin- 
istered the  gas  with  a  hooded  inhalator.  The  patient  took  the 
gas,  and  it  was  not  noticed  that  he  became  asphyxiated,  and 
that  gradually  respiration  failed.  The  operator,  instead  of  en- 
deavoring to  resuscitate  the  patient,  extracted  the  tooth,  when 
it  was  found  that  the  patient  was  dying,  and  respiration  and 
heart  had  ceased  their  functions.  Every  means  was  then  em- 
ployed, but  without  results. 

Deaths  from  Mti'ous  Oxide  Gas. 

Out  of  the  seven  deaths  reported  from  nitrous  oxide,  those 
who  have  absolute  faith  in  its  non-giving  death  qualities  allow 
that  there  are  only  two  well-authenticated  cases  which  they  are 
willing  should  be  classed  as  true  deaths.  In  this  edition  we 
have  retained  only  one  of  the  seven  which  we  reported  before, 
but  in  this  case  the  operator  thought  we  were  a  little  unfair,  so 
we  have  received  his  own  statement  of  the  facts  as  follows : 
*  "The  particulars  of  Mr.  C.'scase  are  these.  He  called  to 
have  two  teeth  extracted  about  12  m.,  and  presented  no  symp- 
tom of  any  kind  contraindicating  his  taking  the  gas.  He  had 
done  so  on  three  or  four  former  occasions.  He  took  the  gas 
well  and  recovered  completely  inside  of  two  minutes,  expressing 
himself  as  really  enjoying  the  experience.  He  sat  in  the  chair 
rinsing  the  blood  away  with  one  glass  of  water,  then  arose  and 
walked  to  the  washstand  to  refill  his  glass,  returning  to  the  chair 
for  further  rinsing.  This  he  did  four  times,  carrying  on 
friendly  conversation  and  consuming  fully  twenty-five  minutes, 
during  which  time  nothing  appeared  to  indicate  anything 
wrong.  When  he  had  finished,  he  walked  to  the  mirror  and  en- 
deavored to  see  the  socket,  using  his  right  hand  to  press  back 
the  lips  and  cheek  (the  teeth  were  second  and  third  molars. 


116  ARTIFICIAL    ANESTHESIA. 

right  upper).  As  he  put  his  hand  down  he  closed  the  fingers, 
and  remarked  that  his  hand  felt  numb.  He  looked  pale,  and  I 
at  first  thought  looking  at  the  wounds  had  made  him  faint,  and 
toU  him  to  walk  over  to  the  couch,  which  he  did,  and  before 
three  minutes  had  passed  his  right  side  was  paralyzed,  and  con- 
sciousness ceased  in  perhaps  ten  minutes. 

"He  lived  until  five  o'clock.  The  coroner  exonerated  the  op- 
erator and  the  anaesthetic,  and  gave  the  verdict  of  death  from 
apoplexy,  which  might  have  been  caused  by  any  excitement." 

Therapeutic  Application  of  Nitrous  Oxide. 

Neuralgia,  uncomplicated,  will  sometimes  be  relieved  by  a 
few  inhalations  of  nitrous  oxide  gas ;  on  the  other  hand,  if  a 
disordered  condition  of  the  stomach  cause  the  neuralgic  pains, 
instead  of  proving  a  relief  it  will  only  aggravate  the  trouble. 

Nervous  Aphonia.— This  peculiar  form  of  loss  of  the 
power  over  the  voice,  usually  the  result  of  hysteria,  will  be 
much  improved  by  the  patient  inhaling  a  sufficient  amount  of 
the  nitrous  oxide  gas  to  produce  a  partial  loss  of  sensation  and 
muscular  relaxation. 

Local  Paralysis  has  been  benefited,  where  there  was  no 
brain  lesion,  by  the  gentle  stimulation  of  the  first  stage  of  the 
gas,  or  the  tingling  and  stimulating  efi'ect  on  the  muscles. 

Asthma. — This  disease,  when  of  a  spasmodic  character,  is 
often  much  improved  by  causing  the  patient  to  pass  into  the 
stage  of  relaxation,  employing  it  every  other  day  for  a  week 
or  two. 

Epilepsy. — When  this  disease  is  not  the  result  of  an  organic 
change  in  the  brain,  spine  or  other  portion  of  the  nervous  sys- 
tem, but  the  result  of  some  peripheral  or  reflex  action,  benefit 
will  ensue  by  the  use  of  the  gas  for  weeks.  It  should  be  ad- 
ministered two  or  three  times  a  week  only,  to  produce  the  stimu- 
lating efi'ects  of  the  first  stage  of  anaesthesia. 

Dr.  George  J.  Zeigler,*  a  friend  of  the  writer,  has  found  the 
solution  of  the  gas  in  water  of  much  utility  in  the  treatment  of 
diseased  conditions  of  the  kidneys  and  bladder. 

*  See  bis  work  on  this  subject. 


THERAPEUTICS    OF    NITROUS    OXIDE    GAS.  117 

This  gas,  we  understand,  either  alone  or  mixed  with  oxygen, 
is  employed  by  certain  individuals  as  a  secret  remedy — a  plausi- 
ble form  of  quackery  kept  up  by  the  most  extensive  and  per- 
sistent advertising. 

Therapeutics  of  Nitrous  Oxide  Gas  according  to 
Dr.  A.  3I*L.aue  Hamilton. 

"For  the  relief  of  severe  paroxysm  of  neuralgic  pain,  this 
gas  stands  high  as  a  remedial  agent.  I  have  used  it  in  cases 
of  severe  and  persistent  facial  neuralgia  and  in  common  sciatica. 
When  hypodermic  injections  of  morphia  have  done  little  or  no 
good,  this  agent  offered  relief,  not  only  temporarily,  but  in  an- 
other way.  Just  as  oxygen  was  useful  in  the  hands  of  Hooper, 
La  Passe,  Hill,  Demarquay  and  others,  so  is  dilute  nitrous  oxide 
in  neuralgic  affections,  and  in  such  cases  the  chemical  haematic 
action  is  that  which  it  produces. 

"  As  yet  I  have  not  used  the  gas  in  the  treatment  of  epilepsy, 
though  I  have  no  reason  to  doubt  its  value  in  a  disease  which  is 
essentially  an  ansemia.  Dr.  Smith  alludes  to  a  case  reported 
by  Wallihan,  who  had  used  mixed  nitrous  oxide  and  oxygen 
with  great  success. 

"  There  is  a  variety  of  insomnia  which  depends  upon  over- 
work and  general  prostration.  Such  a  case  came  under  my 
care  in  the  person  of  the  president  of  a  college  who  was  on  his 
way  to  Bermuda  in  pursuit  of  a  change  of  air  and  scene.  He 
was  persuaded  to  come  to  me  by  a  patient  who  had  taken  the 
gas.  He  had  not  slept  for  some  time,  except  for  a  few  hours, 
and  then  he  was  tortured  by  bad  dreams.  After  daily  taking 
four  gallons  of  gas  he  slept  soundly  three  nights  out  of  four, 
and  there  would  have  been  no  exception  had  he  not  excited 
himself  in  preparing  for  his  trip.  In  other  cases  the  gas  acted 
very  badly  when  it  was  given  at  night,  for  although  drowsiness 
succeeded  the  administration,  there  was  a  secondary  stage  of 
excitement  of  a  disagreeable  kind  ;  I  therefore  followed  the 
suggestion  of  my  friend.  Dr.  Blake,  and  administered  the  gas 
in  the  middle  of  the  day,  and,  found,  as  a  consequence,  that  the 
insomnia  was  overcome.  Probably  the  beneficial  effects  arose 
from  a  general  equalization  of  the  circulation  and  the  removal 


118  ARTIFICIAL    ANESTHESIA. 

of  effete  nervous  tissue  from  the  perivascular  spaces.  In  such 
examples  of  insomnia  dependent  upon  slow  removal  of  waste 
products  of  cerebral  action,  the  circulation  of  vitiated  blood  in 
consequence  of  hepatic  or  renal  disease,  or  depressed  tone  of  the 
cerebral  vessels,  nitrous  oxide  gas  was  indicated  and  tried  with 
success.  In  clearly  asthenic  cases,  however,  in  which  the  sleep- 
lessness depended  upon  excitement,  vascular  engorgement  of  a 
congestive  character,  or  active  cerebral  hyperaemia  in  connec- 
tion with  hypertrophy  of  the  left  side  of  the  heart,  and  increased 
vascular  tension,  the  employment  of  nitrous  oxide  was  contra- 
indicated,  and  did  no  good.  In  fact,  in  one  case  it  aggravated 
the  wakefulness. 

"In  some  forms  of  functional  heart  disorder  I  have  witnessed 
results  which  fulfilled  all  my  anticipations.  In  cases  connected 
with  hypochondriasis  its  virtues  were  most  apparent,  and  many 
an  imaginary  trouble  ceased  to  annoy  the  patient  when  his  in- 
tellectual functions  were  restored  to  a  normal  condition. 

"  In  one  case  of  functional  heart  trouble,  attended  by  palpi- 
tation, depression,  sinking  feelings,  and  an  indescribable  pang 
which  followed  physical  exercise,  in  the  person  of  a  well-known 
literary  gentleman  of  middle  age,  whose  sufferings  were  depen- 
dent upon  many  years  of  hard  intellectual  labor,  I  was  glad  to 
find  that  after  two  or  three  days  his  trouble  disappeared  to  a 
great  extent,  and  probably  in  a  younger  subject  would  have 
vanished  altogether.  In  his  case,  however,  there  were  probably 
deeper  troubles.  For  chlorotic  young  women  who  suffer  from 
ovarian  irregularities,  head  troubles  and  palpitation,  nitrous 
oxide  does  much  good. 

"The  vague  muscular  pains,  irregularity  of  heart  action,  loss 
of  appetite,  tremor,  sinking  sensations,  and  nervous  irritability, 
so  common  among  those  who  use  tobacco  to  excess,  form  a  train 
of  symptoms  which  disappear  very  rapidly  under  the  influence 
of  gas,  and  the  irritability  of  opium  eaters,  and  those  who  drink 
to  a  degree  that  brings  them  to  the  verge  of  acute  alcoholism , 
subsides  very  quickly.  For  this  reason  dilute  nitrous  oxide  ' 
may  be  given  to  persons  who  suddenly  part  with  their  accus- 
tomed opium  or  alcohol,  and  with  a  fair  show  of  permanent 
success,  for  an  agent  which  not  only  supplies  oxygen  but  im- 


SAFETY    IN    DISEASE    OF    NITROUS    OXIDE    GAS.       119 

proves  the  nutrition  of  worn-out  tissue,  and  supplies  at  the 
same  time  a  stimnhmt  without  reaction  cannot  fail  to  bridge 
the  patient  over  the  period  of  acute  suffering  and  intense  irrita- 
bility in  the  beginning." 

Dr.  Colton  on  the  Safety  in  Disease  of  Nitrous 
Oxide  Gas. 

"Is  it  safe  in  the  various  organic  diseases,  such  as  those  of 
the  heart,  lungs,  brain,  etc.  ?  Thousands  of  invalids  have  suf- 
fered torture  for  months  and  years  because  they  dreaded  the 
surgeon's  knife,  and  in  like  manner  other  thousands,  suffering 
from  some  organic  or  functional  disorder  of  the  system,  have 
dreaded  the  dentist's  forceps,  and  fearing  to  take  an  anaesthetic, 
have  for  years  carried  in  theii'  mouths  a  mass  of  filth,  a  fruitful 
cause  of  disease,  which  has  not  only  ruined  their  health  and 
destro3^ed  their  happiness,  but  made  them  objects  of  repugnance 
to  all  who  are  so  unfortunate  as  to  be  associated  with  them. 

' '  If  the  above  question  can  be  answered  in  the  affirmative  ; 
if  nitrous  oxide  is  safe  for  such  afflicted  ones,  it  is,  certainly,  a 
great  boon  to  suffering  humanity. 

"  Having  used  it  almost  indiscriminately  for  years,  I  present 
below  the  results  of  my  experience  : 

"  Disease  of  Lungs. — It  is  a  well-established  fact  that  pure 
nitrous  oxide  gas  is  entirely  non-irritating  to  the  lungs,  and  as 
we  have  already  shown,  its  action  upon  the  blood  is  to  increase 
the  property  of  coagulation.  A  person  who  is  predisposed  to 
haemorrhage  can  inhale  the  gas  with  entire  immunity  from 
danger — indeed,  I  think  with  less  danger  than  would  attend 
the  operation  if  no  anaesthetic  were  administered,  since  the 
shock  to  the  system  is  thereby  avoided,  and  there  is  but  a  slight 
increase  in  the  force  of  the  circulation.  In  a  large  number  of 
such  cases  where  the  gas  has  been  administered  for  tooth- 
extraction  I  have  never  met  with  one  where  any  haemorrhage 
followed  immediately  succeeding  the  operation,  nor  any  in 
which  the  after-effects  proved  unpropitious  ;  and  this,  notwith- 
standing a  large  number  have  had  haemorrhages  previous  to  the 
operation,  and  some  immediately  succeeding  it.  I  should  state 
here  that,  in  all  cases  of  disease,   the  effects  of  the  gas  are 


120  ARTIFICIAL    ANAESTHESIA. 

watched  with  the  greatest  care,  and  if  any  untoward  symptoms 
present  themselves,  it  has  been  discontinued,  although  this  has 
never,  in  a  single  case,  been  found  necessary  until  the  patient 
was  sufficiently  under  its  influence  to  permit  of  a  momentary 
operation  ;  as  for  instance,  the  extraction  of  a  tooth. 

■'Heart  Disease. — In  this  disease  the  effects  should  be 
watched  with  care,  and  there  will  be  no  danger.  The  cumu- 
lative action  of  the  gas  is  only  for  a  few  seconds,  so  that  if  it 
be  withdrawn  at  any  time  during  the  process  a  reaction  takes 
place  in  a  moment,  we  might  almost  say  before  the  patient  has 
time  to  die  ;  while  with  ether  and  chloroform  there  is  a  cumu- 
lative action  for  from  20  to  50  seconds  after  they  have  been 
discontinued,  and  several  minutes  may  elapse  before  conscious- 
ness returns.  Although  its  evanescent  character  is  a  great 
obstacle  to  its  use  for  long  operations,  still  that  is  the  great 
safeguard  against  accident,  for  the  heart's  action  may  be  under 
your  control,  as  the  engine  is  under  the  control  of  the  engineer. 
If  the  pressure  is  too  great,  he  lets  off  the  steam  ;  if  the 
heart's  action  is  either  increased  or  diminished  inordinately, 
remove  the  gas  and  in  a  moment  it  resumes  its  wonted  action. 

"  In  two  recorded  cases  the  condition  of  the  patient  was  so 
critical  that  I  should  scarcely  have  dared  to  extract  a  tooth 
without  the  use  of  an  anaesthetic,  fearing  the  shock  to  the 
system  incident  to  the  operation,  there  being  in  one  case  a 
complexity  of  diseases — hypertrophy,  dilatation  and  valvular 
disease,  which  had  been  continued  for  12  years.  He  had 
formerly  followed  the  sea,  but  had  not  been  able  to  go  upon 
the  streets,  without  assistance,  for  several  years.  He  was  pale 
and  ansemic,  with  an  irregular  and  intermittent  pulse. 

"The  administration  of  the  gas  was  continued  only  to  near 
the  close  of  the  second  stage  ;  the  patient  recovered  without 
any  untoward  symptoms,  and  left  the  office  in  a  few  moments 
declaring  he  felt  better  than  when  he  came  in.  He  certainly 
looked  much  better,  having  lost  that  deathly  pallor  of  face 
which  he  had  when  he  sat  in  our  operating  chair.  The  danger 
in  such  cases  is  that  the  feebleness  of  the  heart's  contractile 
power  may  cause  its  action  to  cease  altogether  during  the  period 
when  this  power  is  partially  destroyed  by  the  paralyzing  action 


SAFETY  IN  DISEASE  OF  NITROUS  OXIDE  GAS.   121 

of  the  anaesthetic,  while  the  safety  lies  in  the  instantaneous 
reaction  after  the  withdrawal  of  the  f^as. 

"In  Chorea,  Hysteria,  Epilepsy  and  other  diseases 
dependent  upon  a  disordered  condition  of  the  nervous  system, 
it  is  productive  of  no  bad  results,  unless  it  be  pushed  too  far ; 
while  if  only  the  second  stage  of  anaesthesia  be  produced,  so 
that  it  shall  act  as  a  stimulant  to  the  nervous  sj^stem,  and  not 
as  a  depressing  agent,  it  will  in  many  such  cases  prove  a  most 
valuable  remedial  agent. 

"Uncomplicated  Neuralgia  is  oftentimes  instantly  relieved. 
I  could  adduce  a  hundred  instances  of  the  kind,  where  the 
patient  has  sat  down  with  a  sevei'e  headache  and  been  entirely 
relieved  by  a  few  inhalations  of  the  gas.  On  the  other  hand,  if 
a  disordered  condition  of  the  stomach  cause  the  neuralo;ic  pains, 
instead  of  proving  a  relief  it  will  only  aggravate  the  trouble, 

"A  lady  who  had  inhaled  ether  a  half-hour  previously  for  the 
extraction  of  some  teeth,  and  had  been  unsuccessful,  came  to 
the  ofl&ce  with  a  severe  headache  ;  she  inhaled  the  gas,  her 
teeth  were  drawn,  and  upon  recovery  she  stated  that  her  head- 
ache was  entirelj^  relieved. 

"Hysteria. — The  gas,  by  its  stimulating  action  upon  the 
nerves,  has  oftentimes  proved  beneficial  in  cases  that  have  come 
under  my  observation. 

"Such  patients  generally  leave  the  office  with  hj^sterical 
symptoms  much  less  aggravated  than  before  the  inhalation. 
During  the  operation,  the  friend  in  attendance  sometimes  ex- 
presses fears  that  the  patient  may  have  one  of  her  'nervous 
spells,'  noticing  some  contortion  of  the  face  or  movement  of 
the  hand  as  she  is  waking  from  a  dream  ;  but  in  a  few  moments, 
as  soon  as  complete  recovery  has  taken  place,  there  is  usuall}'' 
a  calmness  of  the  patient  quite  surprising  to  the  attendant, 
she  being  able  to  write  her  name,  with  as  steady  a  hand  as 
usual,  within  five  minutes  of  the  commencement  of  inhalation. 

"I  have  the  record  of  an  interesting  case  of  a  young  lady 
who  had  not  been  able  to  speak  above  a  whisper  for  several 
months  previous  to  taking  the  gas,  who,  a  few  days  subsequent, 
called  and  informed  me  with  the  greatest  delight  that  she  had 
been  cured,  as  she  could  talk  now  as  well  as  ever. 

9 


122  ARTIFICIAL    ANAESTHESIA. 

"The  fact  that  she  awoke  after  the  operation  crying  out  may 
have  had  some  agency  in  effecting  the  cure,  as  she  thus  learned 
that  she  possessed  vocal  organs  and  could  use  them. 

"Still,  this  case,  in  connection  with  very  many  others  of  a 
like  character,  has  convinced  me  that  pure  nitrous  oxide  may 
be  employed  with  great  advantage  in  cases  of  hysteria  ;  while, 
on  the  other  hand,  if  it  be  impure,  either  on  account  of  its 
being  prepared  so  recently,  or  for  too  long  a  period,  or,  if  per- 
sisted in  beyond  the  third  stage,  it  is  absolutely  injurious. 

"Asthma. — Asthmatic  patients  express  a  sense  of  relief  after 
inhaling  the  gas  which,  in  some  instances,  at  least,  seems  to  be 
of  a  permanent  character.  A  gentleman  of  sixty  years,  whose 
disease  was  inherited,  and  who  had  been  a  severe  sufferer  for 
many  j'ears,  was  almost  entirely  relieved  for  a  whole  winter  by 
inhaling  for  a  few  successive  days,  once  or  twice  each  day,  a 
quantitj'-  sufficient  to  produce  the  second  stage  of  anaesthesia, 
although  he  had  not  been  free  from  the  disease,  at  this  season 
of  the  year,  for  about  twenty  years. 

"Paralysis. — Quite  a  number  of  patients  afflicted  with 
paralysis,  in  a  greater  or  less  degree,  have  come  under  my  ob- 
servation upon  whom  the  gas  has  had  a  very  pleasing  effect  in 
stimulating  the  nervous  S3^stem  to  action,  and  thus  restoring  the 
tone  of  the  paralyzed  parts  more  or  less  completely. 

"  One  such  case  was  that  of  a  gentleman  who  had,  for  a  long 
time,  been  afflicted  with  paralysis  of  the  bladder.  He  inhaled 
the  gas,  upon  several  occasions,  for  the  relief  of  neuralgia. 
After  a  few  inhalations,  the  paralyzed  condition  was  much  im- 
proved, as  was  evinced  by  his  freedom  from  incontinence.  It 
is  necessary,  in  such  cases,  to  produce  only  the  second  stage  of 
anaesthesia. 

"Epilepsy. — The  following  cases  of  epilepsy  are  of  consid- 
erable interest : 

"  Case  1. — A  young  man,  28  years  of  age,  who  had  inherited 
the  disease,  inhaled  the  gas  for  six  weeks,  two  or  three  times  in 
a  week.  During  the  first  week  he  had  three  epileptic  attacks  ; 
during  the  second  week,  two;  during  the  third,  one;  and  for 
the  three  weeks  succeeding,  not  any. 

"I  presented  the  case,  at  the  time,  at  the  University  clinics, 


NITROUS    OXIDE    AND    OXYGEN    IN    LABOR.         123 

but  liave  never  been  able  to  obtain  its  subsequent  history. 
Previous  to  inhaling  the  gas  he  had  had  two  or  three  attacks 
daily,  and  he  had  not  been  free  from  them  for  so  long  a  time 
for  several  years.  Two  years  previously  he  had  inhaled  the 
gas  for  tooth  extraction  with  a  favorable  result,  which  he,  at 
tlie  time,  attributed  to  the  bromide  of  potassium  which  he  was 
taking. 

"  Case  2. — A  young  lady  inhaled  the  gas  as  a  remedy  in  the 
same  disease.  She  recently  informed  me  that  she  had  not  had 
an  attack  for  several  months,  although  before  this  she  had  ex- 
perienced them  frequently.  She  attributes  her  freedom  from 
attacks  to  the  remedial  efficacy  of  the  gas." 

Nitrous  Oxide  and  Oxyg-en  as  an  Anaesthetic  in 

Labor. 

The  great  advantages  of  nitrous  oxide  as  an  anaesthetic  have 
induced  various  observers  to  endeavor  to  find  a  method  of  ad- 
ministering the  gas  continuously,  so  as  to  keep  up  the  anes- 
thetic influence  for  a  sufficient  length  of  time  for  the  perform- 
ance of  surgical  operations. 

Paul  Bert,  some  years  ago,  made  experiments  with  animals 
in  a  chamber  of  compressed  air,  a  mixture  of  nitrous  oxide  and 
oxygen  being  inhaled. 

He  found  that  anaesthesia  could  be  kept  up  for  a  long  period, 
and  he  urged  the  construction  of  such  chambers  for  operating 
upon  the  human  subject. 

Some  few  experiments  were  made  in  minor  surgery,  but 
nothing  on  a  large  scale  was  attempted  on  account  of  the  ex- 
pense, etc. 

In  1881  Dr.  Si  Klikovich,  in  St.  Petersburg,  made  some  ex- 
periments on  himself  with  a  mixture  of  nitrous  oxide  and 
oxygen,  in  the  proportion  of  eighty  to  twenty,  without  any  in- 
crease of  atmospheric  pressure,  with  a  satisfactory  result.  He 
also  used  it  for  alleviating  the  pains  of  labor,  and  found  it  very 
successful  and  perfectly  safe,  the  great  objection  to  it  being  its 
expense,  and  the  cumbersome  nature  of  the  required  apparatus. 

Professor  Zweifel,  of  Erlangen,  erected  the  necessary  appa- 
ratus for  the  supply  of  the  mixed  gases  to  the  accouchement 


124  ARTIFICIAL    ANAESTHESIA. 

ward  of  his  obstetric  clinic.  He  finds  it  best  to  administer  the 
gases  continuously  during  the  latter  part  of  the  labor,  when  the 
pains  are  most  severe,  not,  as  was  practiced  by  Klikovich, 
merely  giving  the  gases  when  signs  of  approaching  pain  ap- 
peared. 

Though  this  treatment  had  been  adopted  in  sixty  patients, 
no  retardation  of  the  process  was  observed. — B.  Med.  Journal., 
November  7,  1885. 

The  Field  Widening^  for  the  Use  of  Nitrous  Oxide 

Gas.-'' 

James  Brown  Burnet,  A.M.,  M.D.,  of  Newark,  N.  J.,  kindly 
furnishes  the  following  report  of  some  cases  treated  by  him  with 
nitrogen  monoxide,  together  with  notes  upon  his  method  of  ex- 
hibiting it,  and  upon  its  probable  future  usefulness  : 

"  Having  during  the  past  nine  or  ten  years  used  very  exten- 
sively and  successfully  in  my  specialty  (diseases  of  the  nasal 
passages,  throat,  and  lungs)  compressed  air,  oxj^gen,  and  more 
especially  nitrous  oxide  (prepared  by  the  S.  S.  White  Dental 
Manufacturing  Company),  I  cheerfully  furnish  a  few  notes  of 
cases  in  which  the  latter  gas,  given  systematically  and  perse- 
veringly,  has  effected  the  most  beneficial  results.  It  has  been 
my  invariable  rule  to  administer  the  nitrous  oxide  in  small  doses, 
a  few  deep  inhalations  with  periods  of  rest  between,  thus  secur- 
ing, not  its  anaesthetic  but  its  tonic  effects.  I  believe  the  pro- 
fession is  just  awakening  to  the  wonderful  therapeutic  value  of 
this  agent,  not  only  in  diseases  (especially  those  of  a  catarrhal 
nature)  of  the  nasal  passages,  throat  and  lungs,  but  also  in  ner- 
vous prostration,  neuralgia;  chronic  headaches,  languid  circula- 
tion, insomnia,  feeble  lung  power,  partial  collapse  of  the  lung 
with  non-resolution  or  pleuritic  adhesions  after  pneumonia  or 
pleurisy,  nervous  diarrhoea,  or  in  nervous  exhaustion  after  long- 
continued  fevers,  etc.  I  acknowledge  that  I  am  an  enthusiastic 
believer  in  nitrous  oxide  inhalations,  having  seen  so  much  bene- 
fit from  them  in  my  own  practice  ;  and  I  the  more  cheerfully 

*  Therapeutic  Uses  of  Oxygen  and  Nitrogen  Monoxide,  Pamphlet, 
p.  143.     The  S.  S.  White  Co. 


THE    FIELD    WIDENING.  125 

furnish  these  few  lines,  as  I  believe  the  field  for  their  use  is 
daily  widening,  and  that  in  a  few  years  this  treatment  adminis- 
tered scientifically,  methodically  and  judiciously  mixed,  as  Opie 
mixed  his  colors,  '  loitli  brains,'  will  be  the  treatment  with  our 
best  practitioners,  and  will  supersede  in  part,  if  not  wholly,  the 
present  general  nauseating  stomach  medication,  and  thus  give 
that  much-abused  poor  organ  a  little  wholesome  rest,  which 
surely  is  '  a  consummation  devoutly  to  be  wished. ' 

"I  will  report  a  few  of  the  more  prosaic  cases,  chronic  in 
nature,  of  every-day  occurrence,  happening  in  my  own  office 
practice. 

"Case  I.  Old  Pleuritic  Adhesions. — Phcv^be  Y.,  spinster, 
aged  51 ;  for  last  eight  years  has  been  greatly  troubled  with 
shortness  of  breath  ;  dull,  heavy  pains  in  right  side,  which 
were  aggravated  by  deep  inspirations ;  has  been  treated  by  va- 
rious physicians  for  suspected  liver  disease,  muscular  rheuma- 
tism, etc.  Careful  questioning  elicited  the  fact  that  eight  years 
ago  she  had  acute  pleuritis,  since  which  time  she  has  been 
troubled  as  above.  Diagnosis,  after  careful  physical  examina- 
tion, old  pleuritic  adhesions,  which  would  account  for  all  the 
symptoms. 

"Treatment:  ten  gallons  of  N2O,  once  each  day,  for  one 
month;  then  administered  every  other  day  for  another  month, 
and  every  third  day  for  the  third  month,  with  steady  improve- 
ment of  symptoms.  Xot  one  drop  of  medicine,  but  good  nour- 
ishment, deep  pulmonary  gymnastics  (inspirations),  and  plenty 
of  out-door  exercise,  Discharged  cured  in  three  months ;  no., 
pain  ;  no  dyspnoea  remaining ;  no  recurrence  ;  adhesions  broken 
down  and  absorbed  ;  free  play  of  both  lungs  ;  ever  since  a  most 
grateful  patient. 

"Case  II.  Acute  Irritative  Painful  Catarrhal  Bronchitis.— 
Rudolph  Gr. ;  aged  27 ;  engraver ;  suffocative,  paroxysmal 
cough,  with  bloody,  muco-purulent  expectoration  for  six 
months  ;  loss  of  flesh  and  strength ;  dj'spnoea,  etc.  .  has  been 
treated  for  phthisis  pulmonalis,  pertussis,  laryngitis,  etc. 

"Diagnosis,  Irritative  bronchitis.  No  pulmonary  complica- 
tions, but  respiratory  murmur  over  both  lungs.  Patient 
greatly  weakened.     Treatment  :  Best  of  nourishment ;  out-door 


126  ARTIFICIAL    ANAESTHESIA. 

exercise  ;  calisthenics ;  salt-water  bathing,  with  vigorous  rub- 
bing night  and  morning  of  whole  body  with  flesh-brushes.  Ni- 
trogen monoxide,  ten  gallons,  twice  a  day  for  fourteen  days, 
then  once  per  diem  for  one  month,  after  that  every  other  day 
for  two  weeks ;  no  medicine.  Discharged  in  two  months  per- 
fectly cured  ;  no  recurrence  ;  works  all  the  time  ;  lungs  and 
bronchi  sound ;  meet  him  frequently  upon  the  streets,  always 
well,  smiling  and  happy. 

"  Case  III.  X^en-ous  Diarrhoea. — Mrs.  N.  ;  aged  47  ;  much 
emaciated ;  has  been  troubled  for  four  months  with  nervous  di- 
arrhoea ;  great  nervous  prostration  ;  partial  loss  of  control  over 
sphincter  ani ;  sent  to  me  for  oxygen  treatment  by  Dr.  E.  Dr. 
E.'s  diagnosis  confirmed.  No  medicine  given  ;  treated  entirely 
by  N2O,  ten  gallons  each  day,  in  divided  doses,  for  one  month, 
then  three  times  a  week  for  three  weeks,  afterwards  twice  a  week 
for  next  fourteen  days.  Discharged  cured  in  about  nine  weeks  ; 
flesh  and  color  regained  ;  normal  condition  of  health  restored. 
In  good  condition  since. 

"Case  IV.  Sluggish  Circulation. — Mrs.  W.  ;  aged  45  ;  dull 
hendaches ;  constant  drowsiness  ;  sense  of  formication  in  right 
arm  and  leg,  numbness,  tingling,  etc.  ;  cold  hands  ;  clammy 
feet.  Treated  by  inhalations  of  N2O,  ten  gallons  each  day  for 
three  weeks,  every  other  day  for  five  weeks,  then  twice  per  week 
for  one  month.  Discharged  in  three  months  cured  of  all  her 
disagreeable  symptoms  (she  had  had  these  sensations  for  over  a 
year  previously) ;  circulation  perfect ;  headaches  gone  ;  perfect 
cheerfulness  regained. 

"  Case  v.  Nervous  Prostration. — Geo.  P.;  aged  42;  stout, 
robust  man,  but  completeh'^  overcome  by  the  cares  of  business 
life  ;  was  recommended  to  me  b}^  one  who  had  been  entirely  re- 
lieved of  a  severe  catarrhal  laryngitis  by  the  same  treatment. 
Patient  was  moody,  irritable  and  melancholic ;  suffered  from  in- 
somnia ;  friends  feared  loss  of  reason,  etc.  ;  had  been  under  the 
best  of  professional  treatment  for  two  years.  Commenced  with 
ten  gallons  of  N2O  once  per  day,  increased  to  twenty  gallons  per 
diem  for  one  month  ;  occasionally  thirty  gallons  in  small  divided 
doses,  then  every  other  day  for  one  month,  the  third  month 
twice  a  week.     The  only  medicine  used  was  wine  of  coca.     Re- 


ON    THE    ACTION    OF    NITROUS    OXIDE.  127 

suits  truly  marvellous.  Cure  now  complete;  sleeps  and  eats 
well  ;  works  hard  ;  head  clear;  is  happ}',  bright  and  strong. 

'■  These  cases  could  be  extended  indefinitely,  as  I  am  using 
the  NjO  daily  and  extensively." 

Then  follows  the  report  of  two  cases  very  similar  to  the 
above. 

On  Insanity  or  Mental  Disturbance  folloAving-  an 

Operation  where  a  Prolonged  Use  of  an 

Anaesthetic  had  been  Employed. 

In  our  former  editions  we  recorded  the  experience  of  Dr. 
George  H.  Savage,  in  which  violent  delirium,  with  insensibility 
of  the  conjunctiva,  ended,  in  three  weeks,  in  complete  demen- 
tia, followed  in  a  chronic  drinker  immediately  upon  nitrous  oxide 
inhalation. 

Dr.  F.  A.  Ashford  also  reports  a  case  of  a  young  woman  who 
grew  faint  and  dizzy  shortly  after  waking  from  nitrous  oxide, 
passed  into  a  condition  of  disturbed  consciousness,  and  found, 
when  she  came  fully  to  herself,  that  her  left  arm  was  useless. 
It  appears  to  Dr.  Wood,  and  we  fully  agree  with  him,  therefore, 
that  nitrous  oxide  should  never  be  administered  when  there  is 
marked  degeneration  of  the  vessels,  and  that  the  danger  of  its 
employment  would  be  especially  great  if  there  should  be  an 
aneurism  with  feeble  walls. — A/ner.  Journ.  Med.  Sci.,  vol. 
Ivii.,  1869. 

We  have  received  the  following  reprint  from  Dr.  Wood,  and, 
while  not  agreeing  with  him  in  his  views  on  the  subject  of  the 
action  of  nitrous  oxide,  we  are  glad  to  place  it  before  our 
readers. 

On  the  Action  of  Xitrous  Oxide  and  of  the  3Iixtiu*e 
of  Xitrous  Oxide  and  Oxygen.* 

Any  reader  uf  the  last  edition  of  my  work  on  Therapeutics 
knows  that  I  believe  that  nitrous  oxide  acts  as  an  ansesthetic  by 

*  By  H.  C.  Wood,  M.D.,  Philadelphia,  Pa.,  Professor  of  Materia 
Medica,  Pharmacy  and  General  Therapeutics,  and  Clinical  Professor 
of  Nervous  Diseases,  University  of  Pennsylvania.  (Eeprinted  from 
the  Dental  Cosmos  for  May,  1S9.3.J 


128  ARTIFICIAL    ANESTHESIA. 

shutting  off  ox3'gen,  and  that  this  belief  is  founded  upon  the 
following  facts  :  that,  as  established  b3'  Jolyet  and  Blanche,  and 
bj^  Elihu  Thompson,  an  animal  will  live  in  nitrogen,  in  hydro- 
gen, or  even  in  a  vacuum,  as  long  as  in  pure  nitrous  oxide ;  that, 
as  shown  by  myself  (see  pp.  104,  105),  the  circulatory  phe- 
nomena of  nitrous  oxide  anaesthesia  are  very  similar  to  those 
which  are  caused  by  the  inhalation  of  pure  nitrogen  or  by  me- 
chanical asphyxia ;  that,  as  shown  by  my  own  experiments,  as 
well  as  bj'  those  of  the  French  observers  above  named,  the  ad- 
dition of  sufficient  oxj^gen  to  nitrous  oxide  prevents  any  anaes- 
thesia; and  finally  that,  as  shown  by  the  French  observers, 
coma  is  not  developed  until  the  oxygen  in  the  blood  is  reduced 
to  three  or  four  per  cent.  On  the  other  hand,  Paul  Bert  states 
that  a  mixture  of  eighty -five  per  cent,  of  nitrous  oxide  and  fif- 
teen per  cent,  of  oxj^gen,  under  a  pressure  of  at  least  two  at- 
mospheres, will  produce  anaesthesia,  and  has  devised  an  appa- 
ratus which,  it  is  stated,  has  been  used  practically  in  Paris  for 
the  purposes  of  surgical  anaesthesia.  Further,  in  the  experi- 
ments of  Jolyet  and  Blanche,  and  in  my  own  experiments,  never 
less  than  ten  per  cent,  of  oxj^gen  was  mixed  with  the  nitrous 
oxide,  and  in  some  of  the  experiments  the  amount  of  oxygen 
in  the  mixture  equalled  that  present  in  the  atmosphere. 

Under  these  circumstances,  it  has  seemed  to  me  well  worth 
while  to  make  a  series  of  experiments  to  determine  the  effects 
of  the  addition  of  a  small  percentage  of  oxj'gen  to  the  nitrous 
oxide  inhaled,  and  to  add  to  the  main  object  of  the  research  the 
investigation  of  the  relations  between  the  time  required  to  pro- 
duce anaesthesia  in  an  animal  by  the  inhalation  of  nitrous  oxide, 
and  that  necessary  for  the  production  of  anaesthesia  in  the  same 
animal  by  complete  exclusion  of  air ;  or,  in  other  words,  by  me- 
chanical asphyxia.  In  these  experiments  a  tracheal  canula  was 
first  tightly  tied  in  the  trachea  of  a  dog,  then  connected  with 
a  rubber  tube,  which,  in  turn,  could  be  either  connected  with  a 
graduated  gasometer,  or  be  completely  stopped  up  by  means  of 
a  tightly  driven-in  cork.  By  the  use  of  mercurial  valves  the 
inspired  and  expired  air  were  entirely  separated,  so  that  the 
animal  never  re-breathed  the  gas  mixture. 

I  have  made  five  experiments  in  which  pure  nitrous  oxide  was 


ON    THE    ACTION    OF    NITROUS    OXIDE.  129 

first  breathed,  then,  after  a  sufficient  lapse  of  time,  nitrous 
oxide  containing  three  per  cent,  of  oxygen,  then  nitrous  oxide 
containing  five  per  cent,  of  oxj'^gen,  and  then  mechanical 
asphj^xia  was  produced.  In  each  case  two  or  more  inhalations 
of  the  pure  or  ox\'genated  nitrous  oxide  were  given,  and  in  re- 
porting below  the  results  of  the  experiments,  the  average  time 
of  the  several  inhalations  in  each  case  is  given.  The  test  for 
the  completion  of  anaesthesia  was  the  complete  abolition  of  all 
conjunctival  reflexes.  As  in  the  dog  these  reflexes  are  verj'' 
persistent,  it  is  probable  that  loss  of  consciousness  and  sensa- 
tion were  reached  a  little  before  the  time  noted  ;  but  the  corneal 
reflex  affords  the  best  practical  test  for  comparative  judgment, 
and  I  therefore  emploj'ed  it.  The  following  are  the  records  of 
the  five  experiments  made  : 


Experiment  L— Small  Dog. 

Pure  Kitrous  Oxide. 

Min. 

Sec. 

Remarks. 

0 

luhalation  began. 

2 

30 

Corneal  reflexes  gone  to  light  touch 

3 

Eeflexes  gone  entirely. 

0 

Inhalation  began. 

•2 

35 

Corneal  reflex  gone  to  light  touch. 

3 

45 

Eeflex  gone  entirely. 

Nitrous  Oxide  with  Three  Per  Cent,  of  Oxygen. 

Min.  Sec.                                            Remarks. 

0  Inhalation  began. 

4  45                   Corneal  reflex  gone. 

0  Inhalation  began. 

4  Corneal  reflex  impaired. 

4  30                   Eeflexes  gone. 

Nitrous  Oxide  idth  Five  Per  Cent,  of  Oxygen. 

Min.  Sec.                                          Remarks. 

0  Inhalation  began. 

6  Eeflexes  unchanged. 

0  Inhalation  began. 

12  Eeflexes  not  impaired. 


130  ARTIFICIAL    ANAESTHESIA. 

Mechanical  Asphyxia. 

Min.      Sec.  Remarks. 

0  Cork  put  iu  tracheal  tube,  so   as  to 

prevent  any   entrance   of  air   into 

the  lungs. 
2        15  Corneal  reflex  gone. 

Experiment  II. 

Pure  Nitrous  Oxide. 


Min. 

Sec. 

Remarks. 

0 

Inhalation  began. 

2 

10 

Corneal  reflexes  gone, 

Nitrous  Oxide  with  Three  Per  Cent,  of  Oxygen. 

Min.  Sec.  Remarks. 

0  Inhalation  began. 

2  30  Corneal  reflexes  impaired. 

4  30  Corneal  reflexes  very  feeble,  but  not 

gone ;  respiration  almost  arrested. 

5  30  Corneal  reflexes  gone. 

Nitrous  Oxide  with  Five  Per  Cent,  of  Oxygen. 

Min.  Sec.  Remarks. 

0  Inhalation  began. 

9  Corneal  reflexes  impaired. 

11  Corneal  reflexes  much  impaired. 

12  30  Corneal  reflexes  same. 

14  Corneal  reflexes  almost  gone. 

15  30  Corneal    reflexes    gone ;     respiration 

regular  and  good.  Half  a  minute 
after  detaching  apparatus  coi*neal 
reflex  had  become  about  normal. 

Mechanical  Asphyxia. 

Min.      Sec.  Remarks. 

0  Cork  put  in  tracheal  tube, 

2        30  Corneal  reflexes  gone. 


ON  THE  ACTION  OF  NITROUS  OXIDE.      131 

Experiment  IIT. 

Pure  Nitrous   Oxide. 


Min. 
0 
2 

Sec. 
20 

KemarKs. 
Inhalation  began. 
Corneal  reflex  gone. 

Pure  Nitrous   Oxide. 

Min. 
0 
2 

Sec. 
10 

Remarks. 
Inhalation  began. 
Corneal  reflexes  gone. 

Nitrous  Oxide  with  Three  Per  Cent,  of  Oxygen. 

Min.      Sec.  Remarks. 

0  Inhalation  began. 

2        30  Corneal  reflexes  impaired. 

4  30  Corneal  reflexes  very  feeble,  but  not 

gone ;  respiration  almost  arrested. 

5  30  Corneal  reflexes  gone. 

Nitrous  Oxide  with  Five  Per  Cent,  of  Oxygen. 

Min.  Sec.                                          Remarks. 

0  Inhalation  began. 

9  Corneal  reflexes  impaired. 

Y^  Corneal  reflexes  much  impaired. 

Y2  30                   Corneal  reflexes  same. 

14  Corneal  reflexes  almost  gone. 

15  30  Corneal    reflexes    gone;     respiration 

regular  and  good.  Half  a  minute 
after  detaching  apparatus  corneal 
reflex  had  become  about  normal. 

Mechanical  Asphyxia. 
Min.      Sec.  Remarks. 

0  Cork  put  in  tracheal  tube. 

2        30  Corneal  reflex  gone. 

Experiment  IV. 
Pure  Nitrous  Oxide. 


Min. 

Sec. 

Remarks, 

0 

Inhalation  began. 

1 

30 

Corneal  reflex  gone. 

132  ARTIFICIAL    ANESTHESIA. 

Nitrous  Oxide  with  Three  Per  Cent,  of  Oxygen. 
Min.      Sec.  Remarks. 

0  Inhalation  began. 

3  Corneal  reflexes  gone. 

Nitrous  Oxide  with  Five  Per  Cent,  of  Oxygen. 
Min.      Sec.  Remarks. 

0  Inhalation  began. 

6  Corneal  reflexes  much  impaired. 

10  Corneal  reflexes  almost  gone. 

19  Corneal  reflexes  gone. 

Mechanical  Asphyxia. 
Min.      Sec.  Remarks. 

0  Cork  put  in  tube. 

1  50  Corneal  reflexes  gone. 

Experiment  V. 
Pure  Nitrous  Oxide. 

Min.      Sec.  Remarks. 

0  Inhalation  began. 

1  45  Corneal  reflexes  gone. 

Nitrous  Oxide  with  Three  Per  Cent,  of  Oxygen. 

Min.      Sec.  Remarks. 

0  Inhalation  began. 

2  50  Corneal  reflexes  gone. 

Nitrous  Oxide  with  Five  Per  Cent,  of  Oxygen. 

Min.      Sec.  Remarks. 

0  Inhalation  began. 

23  Corneal  reflexes  gone. 

Mechanical  Asphyxia. 
Min.     Sec.  Remarks. 

0  Cork  put  in  tube. 

1  40  Corneal  reflexes  gone. 

The  following  table  gives  the  results  obtained  in  these  experi- 
ments. Where  one  or  more  inhalations  of  the  same  character 
were  made  in  the  single  experiment,  the  average  of  the  respec- 


ON    THE    ACTION    OF    NITROUS    OXIDE. 


13a 


tive  times  required  to  cause  complete  anaesthesia  is  given  in 
the  table  : 

Time  Required  for  Anesthesia. 


Exp.  No. 

1   Pure  Nitrous 
'         Oxide. 

Nitrous  Oxide 

with  3  Per 
Cent.  Oxygen. 

Nitrous  Oxide 

with  5  Per 
Cent.  Oxygen. 

Mechanical 
Asphyxia. 

1 
2 
3 
4 
5 

!  Min.       Sec. 
3          27 
2           10 
1     2           15 
1     1           30 
!     1          45 

Min.       Sec. 

4  37 

5  30 
5           30 
3 

2          50 

Min,      Sec. 

15         30 
15         30 
19 
23 

Min.       Sec. 
2           15 
2           30 
2          30 
1           50 
1           40 

In  taking  the  average  of  the  five  experiments  it  will  be  noted 
that  two  minutes  thirteen  seconds  were  required  to  produce 
complete  anaesthesia  with  pure  nitrous  oxide  gas,  while  in 
mechanical  asphyxia  the  same  result  was  reached  in  two  min- 
utes nine  seconds.  The  correspondence  between  these  two 
periods  is  very  close — so  close,  indeed,  as  to  give  the  very 
strongest  evidence  of  the  truth  of  the  theory  that  nitrous  oxide 
anaesthesia  is  really  a  form  of  asphyxia.  As  the  carbonic  acid 
in  the  blood  in  mechanical  asphyxia  must  count  for  something, 
it  is  remarkable  that  the  nitrous  oxide  period  was  only  four 
seconds  longer  than  that  of  the  asphj^xia. 

The  effect  of  the  introduction  of  a  little  oxygen  into  the 
nitrous  oxide  was  very  pronounced  ;  three  per  cent,  of  oxygen 
caused  the  average  time  required  for  the  production  of  anaes- 
thesia to  lengthen  from  two  minutes  and  thirteen  seconds  to 
four  minutes  and  seventeen  seconds,  while  the  introduction  of 
five  per  cent,  of  oxygen  increased  the  period  to  eighteen  min- 
utes and  fifteen  seconds.  This  effect  of  oxygen  is,  of  course,  a. 
very  strong  corroboration  of  the  asphyxia  theory. 

After  the  completion  of  the  five  experiments  I  made  one 
trial  of  the  effect  of  the  inhalation  of  a  mixture  of  nitrous 
oxide  with  eight  per  cent,  of  oxj^gen.  The  inhalation  was  con- 
tinued during  half  an  hour,  at  the  end  of  which  time  the  cor- 
neal reflexes,  although  impaired,  were  still  quite  active.  The 
supply  of  gas  giving  out,  my  experiment  was  ended,  but  cer- 
tainly it  was  continued  long  enough  to  decide  that  eight  per 


134  ARTIFICIAL    ANESTHESIA. 

cent,  of  oxygen  will  in  the  dog  indefinitely  postpone  the  pro- 
duction of  complete  anaesthesia.  That  the  system  is  affected, 
however,  was  shown  by  the  fact  that  mechanical  stoppage  of 
the  tube  at  the  end  of  the  half-hour  produced  very  few 
struggles,  complete  insensibility  occurring  in  less  than  a 
minute. 

The  results  which  I  have  reached  in  this  paper  indicate  that 
theoretically  it  is  possible  to  get  a  mixture  of  oxygen  and 
nitrous  oxide  which  will  contain  sufficient  oxj^gen  to  maintain 
for  a  length  of  time  the  vital  function,  and  j-et  have  so  little 
oxygen  that  consciousness  would  be  lost.  The  zone,  however, 
between  unaccompanied  loss  of  upper  brain  function  and  loss 
of  respiratory  and  heart  power  is  such  a  narrow  one  that  it  does 
not  seem  to  me  probable  that  the  surgeon  can  avail  himself 
practically  of  the  existence  of  this  zone  ;  the  danger  of  passing 
suddenly  from  anaesthesia  into  sensibility,  or  from  partial  into 
complete  asphyxia,  would  alwa^^s  be  too  imminent.  Another 
difficulty  would  lie  in  the  great  length  of  time  required  to  pro- 
duce anaesthesia  with  a  combination  of  oxygen  and  nitrous 
oxide.  It  is  not  possible  by  experiments  upon  the  lower  ani- 
mals to  determine  accurately  the  exact  percentage  of  oxj-gen 
which  the  surgeon  should  mix  with  his  nitrous  oxide,  when 
essaying  to  make  use  of  the  zone  just  above  spoken  of  My 
experiments  seem  to  show  that  in  the  dog  six  per  cent,  of  oxy- 
gen in  the  nitrous  oxide  is  probably  the  nearest  approach  to  a 
practical  anaesthetic  mixture  that  can  be  made.  It  is  probable 
that  in  man  a  larger  proportion  of  oxygen  could  be  used,  as  I 
was  rather  surprised  to  find  the  powerful  effect  upon  myself  of 
two  or  three  deep  inhalations  of  nitrous  oxide  containing  five 
per  cent,  of  oxygen. 

The  conclusions  which  seem  to  be  reached  by  the  present 
research  are,  first,  confirmation  of  the  view  that  nitrous  oxide 
produces  anaesthesia  by  cutting  off  the  supply  of  ox^'gen  ;  sec- 
ond, that  a  mixture  of  nitrous  oxide  with  oxygen  does  not 
seem  to  be  available  as  a  practical  anaesthetic. 

We  have  already  stated  our  reasons  why  we  differ  from  Dr. 
Wood  in  so  far  that  nitrous  oxide  has  powers  as  an  anaesthetic, 
producing  sleep,  freedom  from  pain,  and  power  to  resist  the 
use  of  the  knife. 


PART    THIRD. 

ALCOHOL  U.  8.— ETHYL  ALCOHOL. 

(CHO.CHOH.) 


CHAPTER    IV. 

Alcohol,  Different  Kinds — The  Alcohol  Eecognized  hy  U.  S.  Phar- 
macopoeia— Absolute  and  Dilute  Alcohols — The  Alcohol  in  Whis- 
key, Wine  and  Brandy — Amylic  Alcohol — The  Physiological 
Action  of  Alcohol — The  Influence  of  Alcohol  on  the  Kidney  and 
Liver — Strychnine  in  Chronic  Alcoholism — The  Toxic  Action  of 
Alcohol — In  Moderate  Doses  the  Action  of  Alcohol  on  the  Heart 
— Heat-producing  and  Waste-preventing  Action  of  Alcohol — 
Physiological  Action  of  Alcohol — Alcohol  as  an  Anfesthetic — 
Views  of  Eichardson,  Link  and  Others — Toxicology — Treatment 
of  Acute  Alcoholic  Poisoning. 

There  are  some  (about)  twelve  different  kinds  of  alcohol,  as 
follows :  Allylic,  amjdic,  benz^dic,  beetylic,  capr3dic,  cet3dic, 
cinnamjdic,  melyssyl,  etc.  But  the  one  which  is  recognized 
by  the  U.  S.  Pharmacopoeia  is  ethyl  absolute  and  diluted. 
The  absolute  alcohol  has  a  specific  gravity  of  0.796,  and  should 
not  contain  but  one  per  cent,  of  water.  It  is  a  colorless, 
volatile  liquid,  boiling  at  172^  F.,  not  congealed  by  cold  at 
166°  F.  It  is  only  employed  for  chemical  purposes  or  for  a 
local  drying,  hardening,  or  deodorizing  agent.  In  aural  surgery 
it  acts  upon  aural  polypi,  depriving  them  of  their  waterj''  consti- 
tuents ;  also  for  preparing  the  diluted  alcohol. 

The  next  form  is  ethylic  alcohol  deodorized,  U.  S.  P.,  spe- 
cific gravity  0.816.  This  is  perfumers'  alcohol — cologne  spirits. 
The  commercial  alcohol  is  ordinarily  free  from  fusel  oil  and 
purified. 


136  ARTIFICIAL    ANiESTHESIA. 

The  alcohol  diliituni  contains  forty-eight  to  six  per  cent,  by 
volume  of  absolute  ethyl  alcohol,  and  having  a  specific  gravity 
of  0.936.  This  is  the  alcohol  which  is  emploj^ed  for  preparing 
tinctures  and  other  pharmaceutical  preparations.  This  form 
can  be  used  internally  in  low  forms  of  fever  and  debility,  assists 
and  aids  digestion,  and  checks  nausea  of  sea-sickness.  Dose  60 
to  240  m.  in  two  to  six  times  its  volume  of  water. 

Alcohol  is  found  to  be  the  active  agent  in  the  officinal  spiritus 
frumenti,  or  whiskey,  and  spiritus  vini  gallici,  or  brandy,  which 
are  obtained,  respectively,  by  the  distillation  of  fermented  grain 
and  fermented  grapes,  and  should  contain  from  forty-eight  to 
fifty-six  per  cent,  of  absolute  alcohol.  Alcohol  in  the  form  of 
wine,  brandy  and  whiskey  is  a  food  within  the  limit  of  5.1  to  ,lj 
per  day. 

Another  alcohol,  which  is  also  used  in  this  country  and  Euro- 
pean countries  for  adulterating,  and  contains  much  amylic 
alcohol,  is  made  from  Indian  corn,  potatoes^  beets,  wood,  etc. 
It  has  a  burning,  acrid  taste  and  unpleasant  odor.  It  is  of  a 
dark-brown  color;  but  this  is  removed  by  filtering  through 
lime,  charcoal  and  alum. 

Physiological  Action  of  Alcoliol. 

It  has  long  been  recognized  that  when  persons  are  under  the 
controlling  influence  of  alcohol,  either  in  the  form  of  wine,  gin, 
whiskey,  or  brandy,  they  may  be  cut,  bruised,  and  bones  broken, 
without  expressing  or  experiencing  much  or  any  pain.  These 
various  agents  were  employed,  as  we  have  before  stated,  long 
before  any  true  anaesthetic  was  discovered,  by  making  the  indi- 
vidual intoxicated.  Whiskey  is  still  quite  common  in  the  hands 
of  our  railroad  surgeons,  being  used  as  a  stimulant  to  produce 
reaction  after  a  shock,  and  was  and  is  resorted  to  alone  or  in 
conjunction  with  chloroform. 

When  alcohol  is  inhaled,  its  efi'ects  are  developed  in  four  dis- 
tinct stages  : 

First  Stage. — There  is  excitement,  flushing  of  the  body,  and 
dilatation  of  the  pupils  ;  after  a  time  there  follows  languor,  and 
the  muscular  movements  become  irregular. 

Second  Stage. — Muscular  prostration  and  labored  breathing, 


ALCOHOL    AS    AN    ANAESTHETIC.  137 

attended  bj^  deep  sighing  movements   and  rolling  over  of  the 
body. 

Tliud  Stage. — Complete  insensibility  to  pain,  with  uncon- 
sciousness to  all  external  objects,  with  inability  to  exert  any 
voluntary  muscular  power.  The  breathing  now  becomes  em- 
barrassed and  blowing,  with  bronchial  rales,  due  to  the  passage 
of  air  through  fluid  that  has  accumulated  in  the  finer  bronchial 
passages.  The  heart  and  lungs,  however,  even  in  this  stage, 
retain  their  functions,  and  therefore  recovery  will  take  place  if 
the  conditions  for  it  be  favorable.  Also,  if  the  body  be  touched 
or  irritated  in  parts,  there  will  be  a  response  of  motion,  not 
from  any  knowledge  or  consciousness,  but  from  reflex  action. 
During  all  these  stages  there  is  no  violent  convulsive  action, 
but,  step  by  step,  a  reduction  of  temperature  ;  so,  at  last,  the 
loss  of  heat  will  become  dangerous,  for  the  cool  body  cannot 
throw  off  the  water  freely,  and  therefore  fluid  collects  in  the 
lungs,  and  there  is  a  risk  of  suffocation,  as  from  drowning.  If 
the  administration  of  the  alcohol  be  continued  when  the  third 
degree  has  been  reached,  there  is  a  fourth  stage,  which  is  that 
of  death.  The  two  remaining  nervous  centres,  which  feed  the 
heart  and  respiration,  cease  simultaneously  to  act,  and  all  motion 
is  over.  If,  however,  after  the  third  stage  of  insensibility  the 
administration  of  the  spirit  be  stopped,  recovery  from  insensi- 
bility and  prostration  will  take  place  on  one  condition,  that  the 
body  be  kept  warm  for  several  hours. 

Alcohol  as  an  Anaestlietic. 

Alcohol  has  been  employed  in  the  form  of  whiskey  as  an 
anaesthetic,  alone,  even  in  capital  operations.  The  following  is 
the  experience  of  Dr.  John  Link." 

In  his  first  case,  which  he  reported,  a  great  shock  was  sus- 
tained, in  a  railroad  accident,  by  a  brakeman  on  the  Indianapo- 
lis and  St.  Louis  Railroad.  Whiskey  alone  was  given.  The 
amputation  was  down  near  the  hip ;  also  an  operation  on  the 

*  Pamphlet  of  8  pages.  Prepared  for  the  International  Medical 
Congress.  By  John  E.  Link,  M.D.,  Terre  Haute,  Ind.,  Chief  Sur- 
geon of  the  Vandalia  E.E.,  etc. 

10 


138  ARTIFICIAL    AXiESTHESIA. 

foot  through  the  metatarsal  bones.  The  patient  asked  for 
water,  and  in  other  respects  seemed  rational  during  the  opera- 
tion, but  died  soon  after  from  shock.  He  then  reports  four 
cases,  with  details  of  temperature,  pulse,  etc.  ;  amputation  of 
right  arm,  right  foot,  secondary  of  two  left  legs.  He  states 
these  are  given  in  detail  as  t.ypical  cases.  If  left  to  choose 
between  whiskey  and  chloroform,  alcohol  would  be  his  pref- 
erence, administered  rapidly,  preserving  a  more  normal  or 
phj'siological  condition  of  the  system  than  either  chloroform  or 
ether. 

There  is  less  drunkenness  at  the  same  stage  of  insensibility  to 
pain  with  the  former  than  with  the  latter. 

With  alcohol  we  have  hyperaemia  of  the  base  of  the  brain,  as 
evidenced  by  the  flushed  face  and  fulness  of  the  features  about 
the  eyes,  mouth,  and  the  lips,  etc.  His  views  are  that  it  has  a 
counteracting  influence  against  shock  and  anaemia  of  the  brain 
from  the  loss  of  blood,  etc.  He  defends  himself  against  the 
charge  that  such  administration  of  alcohol  leads  to  tippling  and 
drunkenness.  He  knew  of  no  case  where  such  had  been  the 
result,  and,  on  the  contrary,  he  might  cite  many  instances  where 
a  repugnance  and  distaste  for  whiskey  had  been  the  result,  even 
in  those  where  an  appetite  for  it  existed  previously,  the  very 
smell  of  whiskey  being  associated  with  the  operation  and  suf- 
fering. 

Desiring  to  have  the  opinion  of  a  gentleman  who  is,  and  has 
been  for  many  years,  one  of  the  surgeons  to  one  of  the  most  ex- 
tensive railroad  companies  in  the  United  States,  I  submitted 
Dr.  Link's  pamphlet  for  his  opinion,  which  we  now  publish,  as 
the  matter  is  of  great  practical  importance: 

"  In  regard  to  the  report  of  Dr.  Link,  I  must  say  that  I  can- 
not fully  indorse  his  ideas  for  the  reason  that  he  gives  credit  to 
the  'Alcohol,'  which,  in  my  opinion  at  least,  is  partly  due  to 
the  chloroform. 

"Before  administering  chloroform  to  a  patient,  I  invariably 
give  2  to  3  ozs.  whiskey,  with  from  i  to  2^  gr.  morphia,  place 
the  subject  on  the  table  (in  case  of  amputation),  and  see  that 
all  clothing  is  loose  and  the  patient's  head  low ;  then  on  a 
towel  or  large  napkin,  folded  in  4  to  6  plies,  I  pour  on  about 


ALCOHOL    AS    AN    ANESTHETIC.  139 

3SS  chloroform,  and  allow  the  patient  to  inhale  it  slowly  at  first, 
adding  3ss  from  time  to  time,  as  required,  until  completely 
under  its  influence.  In  this  way  it  is  seldom  that  more  than 
5SS  is  required  in  an  ordinary  amputation. 

"If  the  patient  does  not  go  under  the  influence  rapidly,  I 
place  my  open  hand  over  the  towel  and  exclude  the  air  for  a 
few  inhalations,  which  always  has  the  desired  effect,  when  the 
hand  should  be  removed." 

The  late  Valentine  Mott,  in  his  essay  on  "Pain  and  Anaes- 
thetics," objects  to  those  agents  which  are  apt  to  disturb  the 
stomach,  and  reports  the  following  case  : 

"I  well  remember  a  case  of  amputation  of  the  thigh  which 
occurred  a  few  years  since  in  mj^own  practice,  where  the  attend- 
ing physician,  notwithstanding  repeated  cautions,  administered 
brandy  to  the  patient  so  freely  as  to  induce  vomiting,  thus  in- 
terfering with  the  continuance  of  the  reaction,  and  inducing  a 
fatal  result.  It  was  an  extensive  cannon  shot  wound  of  the  knee- 
joint,  and  the  operation  was  performed  on  the  third  day  from 
the  injury,  before  collapse  had  sufficiently  passed  off." 

These  various  alcohols  have  all  a  toxic  action  when  given  in 
sufficiently  large  doses.  The  general  effect  they  produce  on  the 
organism  is  epilepsy,  amblyopia,  insanity  and  paralysis,  affect- 
ing the  nerve  centres  in  the  inverse  order  of  their  development. 
Their  lethal  power  and  the  symptoms  they  produce  are  modi- 
fied by  the  physical  characters  and  the  quantity  administered. 

Yet  it  has  been  found  that  in  moderate  doses  alcohol  caused 
great  increase  in  the  rate  and  force  of  the  cardiac  beat  and  cor- 
responding rise  of  the  arterial  pressure,  and  that  these  phe- 
nomena were  not  affected  by  previous  division  of  the  pneumo- 
gastrics,  of  the  accelerators  of  the  spinal  cord.  There  is  also, 
in  these  small  doses,  a  sensation  of  warmth  and  an  increase  of 
heat,  while  in  very  large  doses  there  is  a  fall  of  temperature 
from  an  increase  of  oxygen  consumed  and  of  carbonic  acid 
eliminated. 

The  exhibition  of  alcohol  has  been  found  to  lessen  the  excre- 
tion of  urea  or  tissue  waste,  while  it  increases  bodily  weight. 
Alcohol  is  a  most  valuable  remedy  in  typhoid  fever  and  diph- 
theria, and  as  a  gargle,  with  water  and  glycerine,  one  of  the  best 
in  laryngitis. 


140  ARTIFICIAL    ANAESTHESIA. 

Conclusions  as  to  the  Physiological  Action  of 
Alcohol. 

In  a  recent  extended  experimental  study  of  the  physiological 
actions  of  alcohol  by  a  young  physiologist,*  late  of  this  city,  he 
arrived  at  the  following  conclusions,  in  which  we  fully  agree 
with  him : 

"1.  Alcohol  in  small  amount  excites,  and  in  large  doses 
depresses,  both  the  peripheral  motor  and  sensory  nerves. 

"2.  Excessive  quantities  cause  a  spiral  degeneration  of  the 
axis-cylinder  of  nerve  fibres. 

' '  3.  Reflex  action  is  first  increased  and  afterwards  diminished 
by  an  influence  exercised  by  the  drug  upon  the  spinal  cord  and 
nerves. 

"4.  In  small  amounts  stimulates  the  cerebral  functions  ;  it 
afterwards,  especially  in  large  quantities,  depresses,  and  finally 
abolishes  them. 

' '  5.  Alcohol  causes  lack  of  co-ordination  by  depressing  both 
the  brain  and  the  spinal  cord. 

"6.  In  toxic  doses  alcohol  produces  hyperasmia  of  brain  and 
spinal  cord,  especially  of  the  lumbar  enlargement  of  the  latter. 

"7.  Small  doses  of  alcohol  produce  increased  rapidity  of  the 
cardiac  beat ;  large  amounts  a  depression  of  the  same.  In 
either  case  the  effect  is  brought  about  mainly  through  direct 
cardiac  action. 

"  8.  The  drug  in  small  quantities  causes  a  rise  of  the  arterial 
pressure  by  a  direct  action  upon  the  heart ;  in  large  amounts  it 
depresses  the  arterial  pressure  similarly  through  cardiac  influ- 
ence. 

"9.  In  large  doses  alcohol  enhances  coagulation  of  the  blood  ; 
in  toxic  quantities  it  destroys  the  ozonizing  power  of  this  fluid, 
causing  a  separation  of  the  haemoglobin  from  the  corpuscles. 

"10.  Alcohol  in  small  quantities  has  little  or  no  eff"ect  on  the 
respiratory  function.  In  large  doses  it  produces  a  depression 
of  both  rate  and  depth  of  the  respiration  through  a  direct 
action  on  the  centres  of  the  medulla  oblongata. 

"11.  The  drug  kills  usually  by  failure  of  the  respiration. 

•'•David  Cerna,  M.D.,  Ph.D.,  Demonstrator  of  Physiology,  Med. 
Dept.  of  the  Univ.  of  Texas.  Proc.  Pan-American  Congress,  p.  220, 
Vol.  I. 


INFLUENCE  OF  ALCOHOL  ON  KIDNEY  AND  LIVER.   141 

"  12.  On  the  elimination  of  carbon  dioxide  alcohol  exercises  a 
varying  action,  sometimes  increasing,  sometimes  decreasing, 
such  elimination. 

"13.  The  action  of  alcohol  on  the  amount  of  oxygen  absorbed 
also  varies  and  may  be  said  to  be  practically  unknown. 

"  14.  The  drug  lessens  the  excretion  of  tissue  waste  both  in 
health  and  disease. 

"15.  In  small  amounts  alcohol  increases  the  bodily  tempera- 
ture ;  in  large  doses  it  diminishes  the  same.  The  fall  of  bodily 
temperature  is  due  mainly  to  an  excess  of  heat  dissipation 
caused  by  the  drug. 

"16.  Alcohol,  in  sufficiently  large  amounts,  has  a  decided 
antipyretic  action,  but  for  the  purpose  of  reducing  abnormal 
high  temperature  should  not  be  used. 

"17.  In  moderate  amounts  alcohol  aids  the  digestive  process. 

"18.  Alcohol  diminishes  the  absorption  of  fats. 

"19.  The  drug  exercises  a  varying  action  on  the  amount  of 
urine  secreted ;  but  it  probably  increases  the  activity  of  the 
kidneys. 

"20.  In  large  doses,  or  when  continuously  used  for  a  long 
time,  alcohol  produces  cirrhotic  changes  in  the  liver  and  paralj^sis 
of  spinal  origin.  It  also  causes  insanity,  epilepsy  and  other 
maladies. 

"21.  Alcohol  is  mainly  burnt  up  in  the  system  when  taken  in 
moderate  quantities,  but  when  ingested  in  excessive  amounts  it 
is  partly  eliminated  by  the  breath,  the  kidneys,  and  the  intes- 
tines. 

"22.  Alcohol  is  a  conservator  of  tissue,  of  general  or  of  vital 
force  ;  and  may,  therefore,  be  considered  a  food." 

Tlie  Inflvience  of  Alcohol  on  tlie  Kidney  and  Liver.* 

"I  have  selected  only  those  cases  where  the  person  died  more 
or  less  suddenly  ;  where  the  history  and  general  appearance 
clearly  showed  that  death  was  due  to  alcoholism,  and  where  all 

*  The  Pig-backed  or  Alcohol  Kidney  of  Drunkards.  Med.  News, 
October  2,  1886.  By  H.  F.  Formad,  M.D.,  also  pamphlet  by  the  same 
author. 


142  ARTIFICIAL    ANAESTHESIA. 

other  factors  in  causing  death  had  been  carefully  excluded  as 
far  as  possible. 

"Through  the  kindness  of  the  coroner  of  Philadelphia,  who, 
of  necessity,  is  called  upon  to  issue  death  certificates  in  such 
cases,  I  have  had,  during  the  last  two  years,  the  opportunity  of 
making  observatfons  which  some  time  ago  numbered  tiDO 
hundred  and  jifty  cases  belonging  strictly  to  the  category  above 
referred  to,  and  mainly  from  my  own  autopsies.  In  this  city, 
with  a  population  of  about  one  million,  there  are  annually  nearly 
two  thousand  cases  of  sudden  death  subject  to  legal  inquiry. 
The  proportion  of  cases  of  alcoholism  appears  thus  remarkably 
large." 

Anatomical  Considerations. — I  have  met  with  two  varieties 
of  the  kidney  lesion  now  to  be  described  : 

First,  a  hard  cyanotic  form  of  the  "pig-backed"  or  alcoholic 
kidney,  in  cases  of  sudden  death  ;  and 

Second,  a  soft  oedematous  form  of  the  same,  in  cases  where 
death  had  been  delayed. 

First  Form. — In  nearly  all  persons  who  died  more  or  less 
suddenly  from  the  direct  effects  of  alcohol,  I  found  the  kidneys 
to  present  the  following  appearances  :  The  kidneys  are  always 
above  the  normal  size ;  they  are  often  from  one-third  to  one- 
half  larger,  and  are  sometimes  even  double  their  usual  size  and 
weight.  They  are  longer  and  thicker  than  normal,  while  their 
width  is  diminished  so  that  the  natural,  characteristic  flat  kid- 
ney, or  bean-shaped  form,  is  changed  to  a  swollen,  rounded, 
sausage-like,  or  ' '  pig-backed  ' '  appearance  or  form.  They  are 
bluish-red  or  livid  in  color  from  being  engorged  to  their  utmost 
capacity  with  venous  blood,  reminding  one  of  the  rounded,  en- 
larged appearance  of  animal  kidneys  when  over-filled  by  some 
artificial  injection  mass.  In  most  cases  these  "pig-backed" 
kidneys  are  elastic,  but  quite  hard  when  freshly  removed  from 
the  body ;  but  unlike  the  cyanotic  induration  from  heart  dis- 
ease, they  gradually  become  softer,  unless  the  renal  vessels  are 
at  once  tied  to  prevent  escape  of  blood  from  them. 

On  section  the  cut  surface  presents  the  same  dark-red  or  livid 
appearance  as  seen  in  the  cardiac  form  of  renal  cyanotic  indura- 
tion.    While  in  the  latter,  however,  the  pyramids  of  the  medul- 


INFLUENCE  OF  ALCOHOL  ON  KIDNEY  AND  LIVER.   143 

lary  substance  are  especially  congested,  in  the  alcoholic  cyan- 
osis the  whole  kidney  substance  is  almost  uniformly  dark  red. 
Dark  blood  oozes  from  the  cut  surface,  and  blood  extravasa- 
tions can  be  often  seen  by  the  naked  eye,  principally  below  the 
capsules. 

Second  Form, — The  other  form  of  alcoholic  kidney  referred 
to  was  met  with  in  persons  who  had  died  some  time  after  a  de- 
bauch (suffering  from  a  few  hours  to  a  few  days  from  delirium 
tremens  previous  to  death).  The  kidne.ys  of  such  subjects  are 
found  to  be  soft  and  flabby  from  oedema,  and  they  are  less  red ; 
otherwise  presenting  the  same  appearance  as  the  hard  variety 
of  alcoholic  renal  cyanosis,  including  the  "pig-back"  shape  of 
the  kidneys. 

Microscopy.  — Sections  were  made  from  a  number  of  specimens 
of  the  alcoholic  kidneys,  care  being  taken  to  examine  microsco- 
pically all  the  different  structural  parts  of  these  organs.  For 
brevity  sake,  only  the  essential  changes  will  be  referred  to. 

The  cortical  and  medullary  portions  of  the  kidney  appear  to 
be  similarly  affected,  but,  as  a  rule,  the  latter  less  so  than  the 
former. 

In  the  hard,  cyanotic  form  of  the  alcoholic  renal  cyanosis  the 
Malpighian  glomeruli  of  the  cortical  portion  are  highly  con- 
gested, and  extravasated  blood  is  seen  within  many  of  the  Mal- 
pighian capsules  ;  some  are  enlarged  to  double  their  normal 
size,  but  the  majority  appear  rather  compressed  by  the  sur- 
rounding swollen  uriniferous  tubules  and  by  the  over-distended 
bloodvessels.  The  latter  (both  arteries  and  veins)  show  thick- 
ened walls,  and  are  deeply  congested  nearly  everywhere  through- 
out the  organ.  The  stellate  veins  in  particular  are  enormously 
distended  and  plugged  up  by  blood  corpuscles  as  in  thrombosis. 
The  Ij^mph  spaces  beneath  the  capsules,  as  well  as  around 
the  tubules,  are  also  dilated  and  distended,  and  are  either 
seen  empty,  or  they  contain  extravasated  blood.  In  some 
sections  the  kidney  structure  gives  the  appearance  of  a  cavern- 
ous change. 

The  epithelium  of  the  convoluted  tubules  is  cloudy,  swollen, 
opaque,  and  the  nuclei  obscured  by  granules,  which,  however, 
become  cleared  up  upon  the  addition  of  a  solution  of  sodium 


144  ARTIFICIAL    ANESTHESIA. 

hydrate.  The  epithelial  cells  appear  to  be  double  their  normal 
size,  and  although  no  visible  desquamation  or  proliferation  of 
the  cells  could  be  noted  in  any  one  of  the  typical  specimens 
examined,  it  appears  that  the  lumena  of  the  tubules  are  oblit- 
erated completely,  as  seen  in  transverse  sections  of  the  tu- 
bules. 

In  the  straight  tubules  of  the  medullary  portion  the  same 
changes  have  been  noted,  but  are  less  marked. 

The  connective-tissue  elements  of  the  pure  alcoholic  kidney 
show  no  pronounced  hyperplasia.  In  the  sections  of  most  of 
the  kidneys  it  is  hardly  perceptible.  Sections  in  which  the  epi- 
thelial lining  was  forcibly  removed  by  means  of  a  camel' s-hair 
brush  showed  the  connective-tissue  to  be  dense,  stiff,  often  pig- 
mented, but  only  moderately  increased  in  a  few  places  around 
the  bloodvessels. 

The  connective-tissue  increase  was  notably  prominent  only  in 
sections  derived  from  occasional  specimens,  which  showed  at  the 
same  time  other  evidences  of  inflammatory  changes  (Bright's 
disease  and  in  cases  complicated  with  heart  disease).  I  do  not 
remember  having  seen  in  one  of  the  sections  of  the  pure 
alcoholic  affection  tube-casts  or  blood  within  the  uriniferous 
tubules. 

In  sections  from  the  soft,  oedematous  form  of  the  alcoholic 
kidney  the  minute  changes  were  essentially  the  same,  but  not 
so  marked  as  those  described  above.  Extravasations  of  blood 
were  less  frequently  seen,  while  the  connective-tissue  elements 
appeared  occasionally  more  or  less  proliferated.  In  sections 
from  some  cases,  however,  no  other  change  could  be  observed 
than  the  very  prominent  cloudy  swelling  of  the  epithelium  pecu- 
liar to  all  the  specimens  of  the  alcoholic  kidney. 

In  alcoholism  we  must  look  to  the  kidney  substance  itself  for 
the  cause  of  the  obstruction  to  the  renal  circulation,  because 
there  is,  as  a  rule,  no  cause  for  it  outside  of  the  kidney  ;  no  dis- 
ease of  the  thoracic  viscera  and  no  thrombosis  of  the  veins. 

Dr.  Formad  states  that  he  has  heard  Virchow  say  that 
"beer  drinkers  have  liypertroplued  kidneys. "  This  view  is  also 
expressed  by  other  pathologists,  but  no  explanation  is  offered, 
nor  have  the  anatomical  peculiarities  of  the  kidneys  of  drunk- 


INFLUENCE  OF  ALCOHOL  ON  KIDNEY  AND  LIVER.   145 

ards  been  described.  In  relation  to  the  pathogenesis  of  the 
alcoholic  renal  cyanosis,  the  following  explanation  suggests 
itself: 

"  It  is  well  known  that  in  persons  who  ingest  great  quantities 
of  fluid,  particularly  alcoholic  beverages  in  dilute  form,  the 
kidneys  are  strained  to  overwork.  The  quantity  of  urine  nor- 
mally passed  by  such  persons  is  enormous  so  long  as  the  kid- 
neys act  at  all,  and  can  at  times  be  favorably  compared  with  the 
quantity  of  urine  passed  in  diabetes.  It  is  evident  that  such 
overwork  must  invite  a  constant  active  (arterial)  hj'persemia, 
which,  of  necessity,  produces  a  hypertrophy,  due  to  a  cloudy 
swelling  of  the  epithelium  and  an  overgrowth  of  all  the  struc- 
tural constituents  of  the  kidnej's.  A  long  continuance  or  a  con- 
stant repetition  of  these  conditions  leads  eventually  to  a  passive 
(venous)  congestion,  which  persists  or  increases  or  subsides  ac- 
cording to  the  repetition  and  the  duration  of  the  debauches  of 
the  drunkard.  The  renal  circulation  of  the  blood  is  retarded 
by  the  pressure  of  the  swollen  epithelium  of  the  uriniferous 
tubules,  as  exerted  upon  the  vessels,  a  pressure  which  the 
thicker  walls  of  the  intertubular  arteries  and  arterioles  can  re- 
sist more  readily  than  the  soft  and  thin  walls  of  the  correspond- 
ing veins.  There  appears  to  be  also  thrombosis  of  the  stellate 
veins.  The  exit  of  blood  is  thus  retarded,  while  the  arterial 
pressure  continues  unabated  and  keeps  the  kidneys  constantly 
■overfilled  with  blood.  Eventually  the  kidne3's  are  filled  to  their 
utmost  capacitj''  with  blood  overcharged  with  carbonic  acid,  and 
in  consequence  also  with  serum,  which,  leaking  out  of  the  ob- 
structed veins  into  the  renal  lymph  spaces,  makes  the  kidney 
tissue  oedematous  ;  blood  extravasates  also,  and  adds  to  the 
firmness,  redness  and  roundness  of  the  organ.  Finally,  the 
renal  circulation  comes  to  an  entire  standstill,  coincident  prob- 
ably with  a  suppression  of  the  urinary  secretion." 

Statistical  Remarhs. — Of  the  250  cases  of  sudden  death 
from  alcoholism  so  far  analyzed,  176  were  men  and  74  women. 
The  hard,  red  form  of  the  "pig-backed"  kidnej"  was  found  in 
men,  principallj'^  in  the  j'ounger  and  middle  aged,  while  the 
softer  oedematous  form  was  more  common  in  men  of  advanced 
age  and  in  the  women.     The  kidnej's  of  which  Bright' s  disease 


146  ARTIFICIAL    ANiESTIIESIA. 

was  coincident  with  the  alcohohc  lesion  were  mostly  those  of 
persons  in  advanced  life. 

The  alcoholic  renal  lesion  was  nearl}^  equally  divided  between 
persons  of  Anglo-Saxon  and  German  descent,  and,  so  far  as  I 
could  perceive,  equally  between  whiskey  and  beer  and  ale 
drinkers.  I  cannot  speak  about  wine  drinkers,  who  in  this 
country  belong  to  the  higher  classes  of  society,  and  are  seldom 
'reached  by  the  scalpel  of  the  pathologist. 

The  brains  of  confirmed  drunkards  should  be  studied  by 
pathologists.  The  claim  that  chronic  drunkenness  is  a  form  of 
insanity  may  perhaps  be  found  to  have  some  foundation. 

The  Medico-legal  Aspect. — A  thorough  knowledge  and  correct 
interpretation  of  the  post-mortem  appearances  of  alcoholism  is 
perhaps  to  no  end  more  important  than  when  the  life  or  welfare 
of  a  fellow-creature  is  at  stake. 

His  experience  has  since  taught  him  that  cirrhosis  with  con- 
traction of  the  liver  is  at  least  as  rare  an  affection  in  drunkards 
as  it  is  in  "teetotalers,"  and  that  the  traditional  "hobnail"  or 
"gin-drinker's"  liver  is  not  diagnostic  at  all,  iDhile  the  large., 
fatty  liver  is  one  of  the  most  important  signs  of  alcoholism.  The 
facts  are  that  in  250  drunkards  he  found  the  enlarged,  fatty  liver 
220  tiynes,  and  the  contracted,  cirrhotic  liver  hut  6  times. 

Often  when  a  drunkard  falls  dead  on  any  occasion  a  cry  of 
murder  is  raised,  especially  when  bruises  are  found  upon  the 
body.  It  is  here  that  a  familiarity  with  the  post-mortem  ap- 
pearances of  fatal  alcoholism  is  particularly  necessary,  and  no- 
where can  ignorance  on  the  part  of  the  examiner  do  more  harm 
than  here. 

The  constant  occurrence  of  the  "pig-backed"  or  alcoholic 
kidney  in  hard  drinkers  who  perished  from  their  drinking,  and 
the  rarity  of  kidneys  of  such  character  in  those  who  are  not 
confirmed  drunkards,  induced  me  to  regard  the  kidneys  as  a 
valuable  sign  in  post-mortem  diagnosis ;  and  next  to  the  pres- 
ence of  alcohol  in  the  stomach,  they  are,  together  with  the 
large,  fatty  liver,  the  most  valuable  proof  that  alcohol  was 
operative  or  had  contributed  in  producing  death. 

The  "pig-backed"  or  alcoholic  kidney,  while  a  valuable 
diagnostic  sign  of  the  effects  of  the  prolonged  abuse  of  alcohol, 


STRYCHNINE    IN    CHRONIC    ALCOHOLISM.  147 

may  not  show  itself  in  persons  who  had  been  but  moderately 
addicted  to  the  use  of  alcohol,  and  in  such  case  alcoholism 
should  not  be  given  as  the  cause  of  death. 

Toxicolog-y. 

Cases  of  acute  alcoholic  poisoning  occur  during  every  few 
months  by  persons  drinking  very  large  quantities,  and  more 
especially  young  persons.  The  treatment  consists  in  the  evacu- 
ation of  the  stomach,  keeping  the  body  warm  and  in  motion 
with  friction  by  the  wet  towel,  and  the  use  of  the  alternate  hot 
and  cold  water  bag. 

Stryclinme  in  Chronic  Alcoliolism. 

From  experiments  we  feel  justified  in  drawing  the  following 
conclusions:  1.  Strychnine  undoubtedly  neutralizes  the  intoxi- 
cating and  narcotic  effects  of  alcohol.  2.  It  enables  large 
quantities  of  alcohol  (when  necessary)  to  be  taken  for  a  consid- 
erable stretch  of  time,  without  causing  the  usual  organic  lesions 
which  follow  the  use  of  alcohol  alone.  3.  There  are,  however, 
limits  beyond  which  the  alkaloid  itself  becomes  injurious  to  the 
organism,  being  a  powerful  poison.  4.  Therapeutically,  strych- 
nine and  the  salts  of  gold  should  be  used  in  all  forms  of  alcohol 
ism.  5.  It  may  be  regarded  as  a  powerful  prophylactic  against- 
alcoholism.  The  usual  dose  is  the  ^  of  a  grain  repeated  at 
intervals  of  from  three  to  six  hours.  In  all  classes  of  cases  it 
must  be  employed  with  caution.  The  antidote  to  strychnine 
poisoning  is  animal  charcoal  or  bone  black,  given  in  water. 


148  ARTIFICIAL    ANESTHESIA. 


CHAPTER   V. 

Ethyl  Ether — Manufacture — Chemical  Eeaction  and  Composition — 
Tests  of  Purity,  Inflammability — Ether  Fortior — Tin  or  Glass 
in  Preserving  Ether — Inflammability  of  Ether — Influence  of 
Ether  on  the  Brain  and  Pulse — The  Ordinary  Method  in  Use  for 
the  Administration  of  Ether :  Towel,  Cone  and  Inhalers — Pre- 
cautions to  be  Employed  Before  and  After  Using  Ether,  and 
Treatment  of  Dangerous  Symptoms. 

Ethyl  Ether. 

Ethyl  Oxide,  the  Ether  of  Commerce. — A  liquid  com- 
posed of  74  per  cent,  of  ethyl  oxide,  and  about  26  per  cent,  of 
alcohol  containing  a  little  water  (U.  S.  P.).  Its  specific  gravity 
is  0.750. 

Ethel  Fortior,  which  is  a  liquid  composed  of  about  94  per  cent, 
ethyl  oxide,  and  about  6  per  cent,  of  alcohol  containing  a  little 
water  and  of  a  specific  gravity  of  0.725  at  15  C.  (59°  F.)  : 

CHI 

Ethyl  Oxide,  Ethyl  Ether,     '    >  0. 

CAJ 

This  body,  commonly  called  ' '  ether, ' '  is  manufactured  on  a 
large  scale  by  heating  a  mixture  of  strong  alcohol  and  concen- 
trated sulphuric  acid  to  140°.  The  reaction  takes  place  in  two 
stages :  in  the  first,  ethyl,  sulphuric  acid,  and  water  are  formed  : 

CA]  H)  aH5]  H] 

^  0  +    yso,=       ^  so,  4-    ^0. 

H    J  HJ  H    )  h] 

The  ethyl,  sulphuric  acid  acts  at  140°  upon  another  molecule 
of  alcohol ;  hydrogen  and  ether  change  places,  and  ether  and 
sulphuric  acid  are  formed  : 

H   J  H  H  CsHJ 


CHEMICAL  AND  PHYSICAL  PROPERTIES  OF  ETHER.        149 

The  ether  and  the  water  produced  are  distilled  off,  whilst  the 
sulphuric  acid  remains  behind,  ready  to  convert  another  quan- 
tity of  alcohol  into  ether. 

The  Chemical  and  Physical   Properties  of  Ether, 

Ether  is  colorless,  very  volatile,  inflammable,  both  it  and  its 
vapor,  which  latter  is  twice  as  heavy  as  ordinary  air,  and  sinks 
therefore  to  the  floor,  which  is  important  to  remember  ;  the 
vapor  becomes  ignited  when  a  light  has  to  be  used,  or  a  heated 
metal.  It  is  soluble  in  alcohol ;  its  odor  is  garlic-like,  strong 
and  pungent.  Its  taste  is  hot,  slightly  soluble  in  water.  Ether 
must  be  kept  in  the  dark  and  in  well  and  carefully  prepared 
tins.  When  in  ordinary  use,  keep  in  an  opaque  glass  bottle ; 
for  if  kept  in  a  hot  place,  or  in  the  tropics,  it  is  apt  to 
change  by  absorption  of  water,  undergoing  decomposition  and 
developing  acetic  acid,  making  it  unfit  for  inhalation.  A  tin 
form  of  bottle  has  been  found  very  useful  in  ordinary  cases. 

The  following  are  some  of  the  methods  of  determining  if  the 
ether  is  pure  for  inhalation  : 

1.  Ether,  if  pure,  forms  a  clear  mixture  with  oil ;  but  if  it 
contains  much  water  or  alcohol,  an  emulsion  will  result, 

2.  Water  is  also  detected  by  adding  tannin  ;  for  when  water 
is  present  the  mixture 'becomes  syrupy,  while,  if  absent,  the 
powdered  tannin  remains  unchanged. 

3.  Alcohol,  if  present,  gives  a  red  stain,  with  crystals  of 
fuchsine ;  it  also  increases  the  specific  gravity. 

4.  Acids,  sulphuric  and  sulphurous,  when  found  in  it,  are 
detected  by  the  precipitates  they  give  with  barium  chloride  ; 
also  an  acid  which  produces  a  deep  red  color  upon  the  addition 
of  an  iron  salt. 

5.  Fusel  oil  may  be  detected  by  leaving  a  greasy  stain  on 
paper,  and,  when  inhaled,  produces  a  burning  and  choking 
sensation — in  some  cases  almost  suffocation. 

The  Inhalation  of  Ether— Etherization,  Anaesthesia. 

Where  ether  is  inhaled  freely,  mixed  with  too  much  air,  it 
produces  intoxication,  with  roaring  and  buzzing  in  the  ears, 


150  AKTIFICIAL    ANAESTHESIA. 

varying  in  its  effects  upon  different  individuals.  In  some  per- 
sons it  causes  depression,  with  weeping ;  others,  elevation  of 
spirits,  indicated  bj^  shouting,  laughing,  singing;  others  dis- 
posed to  fight  or  strut  about  declaiming,  imagining  themselves 
upon  the  stage.  When  still  semi  conscious,  there  is  a  feeling 
as  if  one's  immediate  surroundings  were  afar  off,  with  visions 
and  illusions.  In  this  first  stage  the  patients  will  open  their 
eyes,  and  a  slight  noise  or  loud  talking  will  arouse  them. 

If  now  almost  all  air  is  withdrawn,  and  the  patient  breathes 
deeply  and  long,  it  brings  about  sooner  or  later  the  second  stage 
of  complete  unconsciousness  or  ether  narcosis ;  but  still  there  is 
muscular  rigidity.  As  soon  as  this  passes  off,  complete  anaes- 
thesia takes  place,  when  the  patient  lies  quiet,  with  slow  and 
regular  automatic  respiration,  and  the  arm,  when  elevated, 
will  fall  as  if  paralyzed,  and  the  eye,  if  touched,  will  not  wink. 
Now  and  then  we  have  a  slight  stertor  in  the  breathing.  This 
is  the  time  for  operation  and  the  partial  withdrawal  of  ether, 
giving  the  patient  sufiicient  ether  to  keep  him  fully  under  its 
influence. 

Very  deep,  stertorous  respiration,  due  to  paresis  of  the  mus- 
cles of  the  palate,  should  be  the  signal  for  allowing  air  to  mix 
with  ether  vapor  or  for  the  entire  withdrawal  of  the  anaesthetic. 
The  usual  appearance  of  the  face  of  the  patient  during  ether- 
ization is  reddish,  lips  especially ;  if  very  marked  pallor  and 
lividity  show  themselves,  indicating  failure  of  heart  action,  the 
ether  is  to  be  stopped  at  once,  and  the  feet  of  the  patient 
elevated  and  the  head  depressed  until  the  color  returns.  An- 
other important  sign  of  danger  is  what  is  termed  shallow 
breathing ;  the  respiration,  from  being  slow  and  regular,  be- 
comes very  much  quickened,  and  then  becomes  slower  and 
slower,  until  it  gradually  ceases  or  intermits  for  long  intervals. 
In  such  case,  stop  the  inhaler  and  admit  cold  air,  or  apply  the 
vapor  of  aqua  ammonia  to  the  nose  ;  or  to  strike  the  chest  with 
the  corner  of  a  wet  towel,  wrung  out  of  ice-cold  water,  applied  to 
the  uncovered  chest  with  some  little  force,  or  drop  a  little  of  the 
ether  on  the  open  chest,  will  generally  cause  the  patient  to  make 
a  sudden  gasp,  and  rouse  the  respiratory  function  to  action. 
If  these  measures  fail,  then  resort  must  be  had  to  artificial 


PRECAUTIONS    TO    BE    EMPLOYED.  151 

respiration,  and  the  prevention  of  great  reduction  of  heat,  as 
the  lungs  are  the  cliief  eliminators,  the  kidneys  only  doing  a 
part,  and  j^et,  if  they  are  diseased,  it  is  apt  to  produce  great 
distress,  and  may  be  the  cause  of  death. 

Precautious  to  be  Euiployed  Before  aud  After 
Usiug-  Ether  as  au  Ausesthetic. 

Ether  should  not  be  inhaled  immediately  after  a  full  meal ; 
indeed,  it  is  better  to  take  only  a  biscuit  or  cracker,  or  a  glass 
of  wine  or  a  teaspoonful  of  brandy  and  water,  or  a«scruple  of 
bromide  of  potassium  in  water,  half  an  hour  before,  always 
avoiding  for  several  hours  previous  the  risk  and  annoj'ance  of  a 
full  stomach.  Nothing  like  solid  food  should  ever  be  allowed  a 
feeble  patient  before  inhalation  for  twenty-four  hours.  If 
nourishment  is  necessary,  let  it  be  of  liquid  character,  like  beef 
tea,  as  solid  food,  not  digested,  has  been  the  cause  of  death  in 
more  than  one  person. 

Perfect  quiet  should  be  enjoined  on  all  around  the  patient,  as 
noise,  or  even  loud  talking,  interferes  with  the  perfect  and  rapid 
action  of  the  anaesthetic.  Nothing  like  a  tight  band  or  gar- 
ment should  prevent  the  free  action  of  the  throat  or  chest,  or 
interfere  with  the  muscles  of  respiration.  False  teeth  should 
always  be  laid  aside  until  after  the  inhalation  is  over. 

An  examination  of  the  kidneys  should  always  be  made  before 
using  ether,  as  they  are  the  active  agents  in  eliminating  ether 
from  the  blood,  and  if  they  are  unaWe  to  perform  this  office, 
and  if  the  skin  is  cold,  moist,  and  inactive,  death  will  super- 
vene by  accumulation  of  mucus  in  the  lungs,  or  congestion  of 
the  brain,  as  in  true  Bright's  disease  of  the  kidneys. 

Avoid  all  excitement  to  the  patient  from  fear,  sight  of  instru- 
ments, too  many  spectators,  noise  of  any  kind,  etc.,  all  of  which 
tend  to  induce  shock.  Have  appliances  for  resuscitation  at 
hand,  and  plenty  of  fresh  air  during  the  administration  of  the 
anaesthetic.  In  ether  the  respirations  and  heart  need  to  be 
watched  during  and  after  ansesthesia,  and  also  prevent  the 
reduction  of  temperature  by  hot  bottles  of  water,  etc. ,  in  the 
later  stages  of  narcosis  from  ether. 


152  ARTIFICIAL    ANAESTHESIA. 

luflaiiiinability  of  Ether, 

Treatment  of  Dangerous  Symptoms.— 1.  Nekton's  plan 
suggests  immediate  inversion  of  the  patient  in  case  of  heart 
failure,  and  artificial  respiration^  keeping  it  up  for  some  time. 
2.  Inhalation  of  gtt.  v.-x.  of  nitrite  of  amyl  may  be  given 
early,  the  tongue  being  drawn  out  to  lift  the  epiglottis,  by 
elevating  the  jaw  (Nancrede).  3.  Stimulation,  in  case  respi- 
ration is  affected,  but  not  entirely  suspended,  should  be  em- 
ployed by  means  of  either  atropine,  ammonia  to  the  nostril, 
cold  towel,  or  injection  of  ammonia  into  the  veins,  or  ice  in  the 
rectum.  4.  Galvanism,  if  employed,  may  be  administered  by 
the  following  methods  :  Herapath's  method  (Lancet,  1852). 
The  positive  pole  is  placed  to  the  nostril  and  the  negative  pole 
over  the  diaphragm.  A  reflex  action  is  thus  excited  between 
the  fifth  pair  and  the  pneumogastric.  This  is  used  chiefly  in 
case  of  respiratory  failure  or  general  galvanic  action. 

Numerous  accidents  have  come  to  our  knowledge  in  which 
the  ether  was  ignited,  and,  although  causing  no  actual  injur}'', 
produced  much  fear  and  confusion. 

Dr.  Squibb  has  seen  ether  take  fire  at  a  measured  distance  of 
fifteen  feet  between  the  source  of  escaping  vapor  and  the  source 
of  fire.  This  ignition  of  ether  vapor  is  apt  to  occur  while 
applying  the  actual  cautery. 

All  agents  that  produce  inebriation,  like  alcohol,  only  increase 
the  collapse,  and  the  patient  must  be  kept  warm  while  under 
its  influence,  or  the  tempm-ature  will  sink  below  the  normal, 
the  skin  become  cold  and  clammy,  with  symptoms  of  collapse. 
The  pulse-rate  falls,  the  breathing  becomes  embarrassed,  and  an 
increase  of  secretion  takes  place  in  the  lungs,  and  death  occurs 
from  pulmonary  oedema  and  respiratory  paralysis,  just  as  in 
drunkards  who  are  exposed  to  cold.  On  account  of  the  simi- 
larity of  their  action,  alcoholic  stimulants  should  not  be  given 
where  a  patient  appears  to  be  sinking  from  ether  administra- 
tion. 

Alcohol  and  ether,  the  more  closely  their  effects  on  the  lower 
animals  are  studied,  the  more  closely  are  they  seen  to  corre- 
spond. Atropia  and  digitalis,  on  the  other  hand,  are  of  some 
value,  but  their  effects  have  been  greatly  magnified  ;  they  could 


PHYSIOLOGICAL    ACTION    OF    ETHER.  153 

be  given  in  much  larger  doses  than  we  are  accustomed  to  and 
without  harm. 

In  considering  the  causes  of  death  from  ether  we  must  not 
forget  that  patients  sometimes  die  of  heart  failure,  collapse,  or 
shock.  The  following  means  have  been  found  valuable  in  such 
cases  :  A  hj^podermic  of  strychnine  administered  half  an  hour 
before  the  anaesthesia. 

Cases  in  which  Ether  Should  Not  be  Employed  as  an 
Anaesthetic,  Except  by  an  Expert  or  with  the  Greatest 
Care. — The  conditions  rendering  anaesthetics  dangerous  are  : 
Fatt}''  degeneration  of  the  heart,  a  prominent  contra-indication 
where  there  is  pain  in  heart. 

Physiological  Action  of  Etiier. 

The  following  experiment  was  made,  allowing  an  animal  fully 
to  recover  from  the  mixed  anaesthetic,  and  placing  it  under  the 
full  effects  of  Squibb' s  ether  fortior  (in  the  University  of  Penn- 
sylvania laborator}",  in  the  presence  of  Prof.  Reichert,  Dr. 
Thomas  and  the  writer). 

Ether  was  crowded  on  it  until  the  respiration  ceased  and  the 

heart  almost  stopped  beating  ;  then  a  solution  of  100th  of  a 

grain  of  sulphate  of  atropia  was  introduced,  to  determine  if  it 

had  any  power  to  stimulate  the  heart  or  restore  respiration  in 

this  stage  ;  but  it  produced  no  such  results,  and  the  animal  was 

dead. 
If  the  same  amount  of  caution  is  employed  in  the  use  of 

this  powerful  agent,  as  in  the  use  of  chloroform,  the  number 

of  deaths  would  be  less.     It  must  always  be  borne  in  mind  that 

in  full  anaesthesia,  no  matter  what  agent  is  employed,  there  is 

a  suspension  of  life  forces,  and  but  a  step  to  death. 

The  administration  of  atropine  may  be  resorted  to,  but  mor- 
phia, subcutaneousl}'^  injected,  will  increase  the  risk  with  ether, 
not  so  much  with  chloroform.  There  are  many  individuals  who 
have  idiosyncrasies,  and  cannot  bear  even  what  is  known  as  a 
small  dose  of  morphia  without  great  disturbance  of  the  stomach 
or  faintness. 

It  has  been  suggested  to  add  atropine  to  the  morphia,  but 
the  experiment  just  related  will  demonstrate  that  it  will  not  re- 
lieve the  heart  when  fullj"  under  the  influence  of  the  stronger 

11 


154 


ARTIFICIAL    ANESTHESIA. 


ether.     There  are  no  agents  which  relieve  the  irritation  of  the 
broncho-pulmonary  mucous  membrane  so  well  as  keeping  the 

Plate  21. 


Ether,  First  Stage. 
Plate  22. 


Ether,  Second  Stage. 
Plate  23. 


Chloroform. 
Plate  24. 


Bromide  of  Ethyl. 

skin  warm,  and  free  from  moisture  or  draughts.     Above  all,  no 
one  should  give  the  ether  who  has  not  some  practical  experi- 


ACTION    ON    BRAIN,    HEART    AND    CIRCULATION.       155 

ence  and  is  not  desirous  of  witnessing  the  operation.  Let  his 
whole  attention  be  given  to  the  patient,  and  never  crowd  the 
ether  after  the  patient  has  become  fully  anaesthetized,  but  keep 
it  off  at  a  distance,  so  that  the  patient  may  get  a  small  portion 
of  it. 

The  foregoing  is  a  more  recent  series  of  sphygmographic 
tracings.  There  will  be  found  a  decided  difference  in  the  pulse 
and  heart  in  these  tracings  :  ether  in  Plates  21  and  22,  chloro- 
form in  Plate  23,  and  bromide  of  ethyl  in  Plate  24. 

It  will  be  noticed  how  much  freer  from  influence  upon  the 
heart  ether  is,  and  how  distinct  and  free  from  dangerous  di- 
crotic impressions  compared  with  chloroform,  which  depresses 
the  action  of  the  heart.  Hydrobromic  ether  is  not  considered 
quite  so  dangerous  as  chloroform. 

The  Action  on  the  Brain,  Heart  and  Circulation 

by  Ether. 

The  functions  of  the  cerebrum  or  brain  are  first  affected  before 
those  of  other  portions  of  the  nervous  system.  After  a  more 
prolonged  inhalation  the  anterior  or  motor  centres  soon  fail  to 
respond  to  mechanical  irritation,  yet  the  functions  of  the 
medulla  oblongata  are  performed. 

If  the  inhalation  of  ether  is  still  further  carried  on,  the  sen- 
sory and  finally  the  motor  functions  of  the  medulla  oblongata 
are  involved,  and  death  occurs  from  a  paralj^sis  of  the  respira- 
tory centres  of  the  heart.  Louget  states  that  he  found  the 
sensory  functions  abolished  very  early,  but  he  has  never  failed, 
in  any  stage  of  the  narcosis  from  ether,  to  get  a  response  from 
the  anterior  part  of  the  cord  by  employing  powerful  galvanic 
currents.  The  elevation  of  the  pulse  line  shows  the  stimulating 
property  of  the  ethereal  influence. 

Plate  25  represents  the  excited  pulse  writing  of  a  small  and 
nervous  female  previous  to  etherization  and  operation. 

Plate  26  represents  the  pulse  writing  of  the  same  patient 
when  steadied  by  etherization.  The  contrast  is  remarkably 
favorable. 

Plate  27  represents  the  pulse  writing  of  a  healthy  young  man 


156 


ARTIFICIAL    ANESTHESIA. 


of  22  previous  to  operation  for  artificial  pupil,  an  affection  which 
had  not  interfered  with  his  general  health. 

Plate  28  represents  the  same  when  taken  under  full  etheriza- 
tion, and  after  the  completion  of  the  operation.     A  comparison 


Plate  2.". 


Plate  26. 


Plate  27, 


Plate  28. 


of  this  pulse  writing  with  that  of  the  natural  soft  pulse,  will;be 
ample  evidence  of  the  safety  of  etherization  in  its  action  on  the 
heart. 

The  Action  of  Ether  upon  the  Circulation. 

According  to  Dr.  Wood,  "  It  is  firml}^  established  by  the  co- 
inciding results  of  very  many  experiments  performed  by  various 
observers,  that  during  etherization  there  is  usually  a  pronounced 


ALLIS'    ETHER    INHALER.  157 

rise  in  the  arterial  pressure,  which  is  commonly  maintained  even 
through  a  prolonged  narcosis,  and  may  continue  after  manifest 
failure  of  respiration.  Sooner  or  later,  if  the  inhalation  be  con- 
tinued, the  rise  of  arterial  i)ressure  is  followed  by  a  fall,  which 
may  progressively  increase  until  the  manometrical  needle  reaches 
almost  zero.  There  have  been  very  fev^  careful  studies  of  the 
details  of  the  action  of  ether  upon  the  circulation,  but  such 
facts  as  we  have  go  to  show  that  the  primary  influence  of  the 
drug  is  to  stimulate  both  vaso-motor  centres  and  heart,  and  that 
during  the  stage  of  low  pressure  there  is  depression  of  the  vaso- 
motor centres  and  also  of  the  heart.  This  belief  in  the  primary 
stimulation  of  the  vaso-motor  centres,  rests  almost  entirely  upon 
the  research  of  Professors  Bowditch  and  Minot,  made  in  1874, 
and  the  subject  is  well  worthy  of  a  careful  restudy.  There  is 
much  reason  for  the  belief  that  in  advanced  and  profound 
ether-narcosis,  the  bloodvessels  are  affected  by  the  direct  action 
of  the  substance  upon  their  coats.'" 

Most  American  surgeons  give  ether  as  an  anaesthetic  by  a 
closed  cone,  in  such  a  manner  that  the  patient  breathes  the 
same  air  over  and  over  again.  This  is  a  very  unsafe  mode,  and 
to  it  is  due,  in  a  large  measure,  the  alarming  prostration  of  the 
patients  while  undergoing  operations.  Some  cases  present 
such  profound  symptoms  of  shock  that  the  operation  has  to  be 
suspended  until  hypodermic  injections  of  brandy,  ether  and 
strychnine  are  given.  Indeed,  in  some  cases,  it  is  with  great 
difficulty  that  the  patients  are  kept  from  dying  on  the  table, 
while  some  die  from  oedema  of  the  lungs.  Fully  impressed 
with  this  idea,  I  advise  them  using  Dr.  Allis'  improved  inhaler, 
and  have  thus  far  found  it  to  act  promptly,  safely  and  eco- 
nomically. 

Allis'  Ether  Inhaler. 

We  present  plates  of  the  apparatus  of  Dr.  Allis  for  the  ad- 
ministration of  ether.  This  instrument  has  been  in  use  in  the 
United  States  and  Europe  for  several  j^ears,  and  may  be  said  to 
have  won  the  foremost  place  among  the  standard  instruments. 

This  and  the  following  plates  are  two-thirds  the  size  of  the 
manufactured  instrument. 


158  ARTIFICIAL    ANESTHESIA. 

It  is  now  made  simpler  and  stronger  than  the  first  that  were 
offered  to  the  profession. 

Plate  29. 


Instrument  complete. 

Description  of  the  Inhaler.— Plate  30  consists  of  a 
metallic  frame  sufficiently  large  to  cover  the  lower  part  of 
the  face.     The  bars  are  nearly  a  quarter  of  an  inch  broad,  leav- 


ALLIS'    ETHER    INHALER. 


159 


ing  a  quarter  of  an  inch  between  each  and  its  fellow.  The 
spaces  are  made  by  a  punch,  which  removes  a  section  from  a 
solid  sheet  of  metal.  It  will  thus  be  seen  that  there  can  be  no 
danger  of  the  bars  giving  way,  as  they  would  were  they  soldered 
upon  a  band. 

In  Plate  31  there  is  a  bandage  partly  laced  between  the  bars. 
It  has  been  passed  from  side  to  side,  dividing  the  instrument 

Plate  30. 


into  parallel  sections.  On  the  right,  a  part  of  the  bandage  may 
be  seen  rolled  up.  When  the  bandage  has  been  passed  between 
all  the  bars,  and  the  hood  or  cover  put  on  (Plate  29),  one  can 
look  through  the  instrument  from  end  to  end,  and  there  is  a 
space  of  nearly  a  quarter  of  an  inch  between  the  several  sections 
of  the  bandage. 


160 


ARTIFICIAL    ANESTHESIA. 


The  advantages  of  this  mode  of  construction  are  as  follows  : 
1.  It  gives  the  patient  (Plate  32)  the  freest  access  of  the  air. 

It  is  necessary  that  the  air  should  be  saturated  with  the  vapor  of 

ether,  by  dropping  from  the  bottle. 

Plate  31. 


2.  It  affords  a  series  of  thin  surfaces,  upon  which  the  ether 
can  be  dropped  and  from  which  it  will  almost  instantly  evapo- 
rate. In  this  respect  it  differs  from  the  sponge,  which  retains 
the  ether  in  a  fluid  state  much  longer.  Should  the  bandage 
become  soiled  a  new  one  can  be  inserted  in  a  few  minutes. 


ALLIS'    ETHER    INHALER. 


161 


3.  By  leaving  the  instrument  open  at  the  top,  the  supply  can 
be  kept  up  constantly  if  desired;  and  as  ether  va-por  is  heavier 
than  air,  there  is  [no  loss  by  not  covering  it.  The  top  should 
never  he  covered. 


Plate  32. 


SNOWDEN 


4.  It  is  kept  clean  by  removing  the  strips  of  white  muslin 
each  time  that  it  is  employed. 
Mode  of  using  the  inhaler : 

1.  Place  a  towel  beneath  the  chin  of  the  patient,  as  experience 
has  taught  that  a  towel  should  always  be  within  reach  in  admin- 
istering anaesthetics. 

2.  Place  the  instrument  over  the  face,  covering  the  nose  and 
chin,  and  let  the  patient  breathe  through  it  before  any  ether  is 


162  ARTIFICIAL    ANAESTHESIA. 

applied.     This  will  convince  him  that  he  is  not  to  be  deprived 
of  air. 

3.  Begin  with,  literall}^,  a  few  drops  of  ether;  this  will  not 
irritate  the  lar^^nx.  Add,  in  a  few  seconds,  a  few  drops  more, 
and,  as  soon  as  the  patient  is  tolerant  of  the  vapor,  increase  it 
gradually  to  its  fullest  eflfect.  When  the  effect  of  the  anaes- 
thetic is  apparent,  a  single  layer  of  a  coarse  towel  may  be  laid 
over  the  nose  and  mouth,  and  the  instrument  replaced.  This 
is  a  wise  precaution  against  vomiting  or  spitting. 

4.  When  the  patient  is  fully  influenced,  it  is  well  to  add  a 
few  drops  at  short  intervals,  and  thus  keep  up  a  gradual  anaes- 
thetic eifect. 

It  was  found  with  Allis'  inhaler  that  the  shortest  time 
required  to  produce  complete  angesthesia  in  a  young  female 
patient  was  three  minutes,  and  the  amount  of  ether  employed 
was  only  one  fluid  ounce.  The  longest  period  required  in  an 
adult  female  was  seven  minutes,  and  the  amount  of  ether  used 
two  ounces  and  a  half.  In  a  few  instances  there  was  hysterical 
tendency  among  the  females.  If  solid  food  had  been  taken, 
vomiting  would  follow,  but  after  liquid,  or  light  forms  of  nour- 
ishment, vomiting  was  very  rare ;  not  more  than  one  in  fifty 
cases.  In  temperate  males  the  time  for  full  anaesthesia  was 
from  five  and  a  half  to  eight  minutes.  Ether  consumed  :  min- 
imum quantity,  two  ounces;  maximum,  three  ounces.  Chloro- 
form cannot  be  inhaled  in  this  apparatus,  as  too  much  is  wasted. 

Now,  in  Allis'  apparatus  there  is  no  chance  for  the  ether  to 
remain  in  its  fluid  state,  which  is  the  case  when  a  strip  of  mus- 
lin is  used,  but  exposed  as  it  is,  on  a  thin  stratum  of  muslin,  it 
yields  its  anaesthetic  principle  promptly. 

To  close  this  apparatus  at  the  top  would  necessitate  ingress  of 
air  at  the  part  surrounding  the  mouth,  for  air  must  be  admitted. 

If  it  be  excluded  at  the  bottom  and  left  open  at  the  top,  the 
advantage  of  having  a  constant  supply  of  ether  dropping  upon 
the  folds  is  very  great. 


A    FOLDING    ALLIS'    ETHER    INHALER. 


163 


A  Folding  Allis'  Ether  Inhaler. 

This  inhaler  is  open  to  the  objection,  though  to  a  less  extent 
than  other  instruments  of  its  class,  of  being  somewhat  cumber- 
some when  carried  about,  and  of  occupying,  therefore,  consid- 
erable space  in  the  operating  satchel.  This  has  been  overcome 
by  slightly  altering  the  shape  of  the  inhaler,  in  such  a  manner, 
as  to  allow  of  its  being  folded  flatwise.  The  accompanying  plates 
will  show  how  this  is  accomplished.  Plate  33  represents  the 
inhaler  folded,  ready  for  placing  in  the  pocket  or  satchel,  in 
which  shape  it  occupies  about  as  much  room  in  the  pocket  or 

Plate  33. 


SNOWDEN 


satchel  as  an  ordinary  visiting  list.  By  a  very  simple  move- 
ment, provided  for  by  bringing  together  the  corners  of  the 
metal  sides,  the  two  long  sides  are  made  to  separate  from  each 
other,  until  the  shape  shown  by  Plate  34  is  formed,  in  which 
position  it  is  securely  held,  by  a  little  bar,  which  swings  over 
from  one  corner,  to  the  one  diagonally  opposite,  and  fastened, 
by  its  bent  extremity,  into  a  socket  provided  for  the  purpose. 
The  only  covering  needed  for  an  Allis'  Inhaler,  is  a  simple 
towel  folded  lengthwise,  in  which  the  instrument  is  inclosed, 
just  prior  to  its  use.  This  can  be  procured  at  the  patient's 
house,  and,  after  the  operation,  unpinned  and  thrown  aside. 


164 


ARTIFICIAL    ANESTHESIA. 


Experiments  with  Allis'  inhaler  by  Dr.  G.  H.  Coburn,  a  resi- 
dent phj^sician  of  Howard  Hospital,  carefullj^  recorded  all  the 
cases,  at  our  request,  occurring  during  two  years,  in  which  this 
form  of  Allis'  inhaler  was  employed  in  the  various  surgical 
operations  .performed  in  the  institution  with  most  satisfactory 
results. 

The  objections  to  this  form  of  apparatus  are : 

1.  That  the  exhaled  vapor  is  not  convej^ed  to  the  floor,  but  is 
diffused  in  the  air,  to  be  breathed  by  the  operator  and  his 


Plate  34. 


SNOWDEN 


assistants.  For  a  single  operation  this  is  not  of  much  import- 
ance, but  where  there  are  a  number  of  cases  the  arrangement  is 
not  conducive  to  the  comfort  of  the  operator. 

2.  The  bandage  of  muslin  across  the  bottom  becomes  clogged 
with  moisture  and  saliva,  and  at  times  by  discharges  from  the 
stomach,  and  cannot  be  so  readily  removed. 

3.  Owing  to  the  peculiar  arrangement  of  the  muslin  strips  it 
is  tedious,  when  it  is  required  for  a  number  of  patients,  to 
remove  or  replace  them. 

In  a  conversation  with  Dr.  Allis  he  stated  that  he  considered 
the  chief  merit  of  his  instrument  was  that  it  thoroughly  and 


A    FOLDING    ALLIS     ETHER    INHALER.  165 

instantaneously  liberated  the  ether,  and  that  while  there  was 
not  the  least  impediment  to  respiration,  yet  all  the  air  was 
impregnated  with  the  anesthetic. 

Neither  ether  nor  chloroform  can  be  inhaled  in  the  pure 
state. 

It  is  always  atmospheric  air,  impregnated  with  the  anaes- 
thetic, that  sustains  life  and  produces  anaesthesia. 

The  expression  ' '  give  him  nothing  but  ether,  exclude  the 
air,"  are  only  relative  terms;  they  simplj^  mean  saturate  the 
air  as  much  as  possible  with  the  ether.  Permit  the  patient  to 
have  no  fresh  air,  but  compel  him  to  breathe  air  charged  with 
ether. 

When  he  first  employed  his  instrument  bystanders  would 
suggest  that  it  be  closed  at  the  top,  so  as  to  permit  no  escape 
of  ether. 

This  will  show  that  the  true  laws  of  ether  were  overlooked ; 
ether  vapor,  while  it  will  diffuse  itself  throughout  an  entire 
room,  is  of  greater  specific  gravity  than  atmospheric  air,  and 
tends  to  the  floor. 

As  germain  to  this  subject,  we  would  direct  attention  to  the 
following  experience  recorded  by  the  late  Dr.  Wm.  Goodell,  of 
Philadelphia,  in  the  course  of  a  recent  paper,  giving  a  year's 
experience  in  ovariotomy : 

"One  of  the  chief  lessons  I  have  learned  from  my  experi- 
ence during  the  past  year  is  to  administer  ether.  Hitherto  I 
have,  in  common  with  most  American  surgeons,  given  this 
anesthetic  by  a  closed  cone,  in  such  a  manner  that  the  patient 
breathed  her  own  air  over  and  over  again.  I  am  now  disposed 
to  think  that  this  is  a  very  unsafe  mode,  and  that  to  it  is  due, 
in  a  large  measure,  the  alarming  prostration  of  the  patient 
while  undergoing  the  operation.  For  instance,  among  the 
twenty-five  cases  of  last  year,  cases  70,  71,  and  82  presented 
such  profound  symptoms  of  shock  that  the  operation  had  to  be 
suspended  until  hypodermic  injections  of  brandy  and  of  ether 
were  made,  and  some  degree  of  reaction  had  set  in.  In  cases 
70  and  71  it  was  indeed  with  great  difficulty  that  the  women 
were  kept  from  dying  on  the  table,  while  case  85  clearly  died 


166  ARTIFICIAL    ANAESTHESIA. 

from  oedema  of  the  lungs.  Now  I  do  not  find  such  alarming 
symptoms  referred  to  in  any  reports  of  cases  by  British  opera- 
tors. I  am  therefore  forced  to  the  conclusion  that  either  under 
the  strain  of  rivalry  they  do  not  operate  in  very  desperate  cases 
or  their  mode  of  administering  anaesthetics  is  a  safer  one  than 
ours.  Fully  impressed  with,  this  idea,  I  have  lately  been  using 
Dr.  Allis'  improved  inhaler,  and  have  thus  far  found  it  to  act 
promptly,  safely,  and  economically. " 

Clover's  Small  Portable  Ether  Apparatus. 

Is  a  very  good  inhaler  (see  Plate  35). 

The  face-piece  is  edged  with  an  air  cushion.  The  ether  ves- 
sel and  warm  water  chamber  which  surround  it  and  maintain  it 
at  the  desired  temperature  for  evaporation  rotate  upon  the 
mouth  of  the  face-piece.  When  the  instrument  is  first  applied 
the  stopper  should  be  opposite  the  patient's  forehead,  and  the 
indicator,  which  travels  round  the  lower  end  of  the  water 
chamber,  pointing  to  the  figure  0.  The  bag  should  not  be 
placed  in  position  until  the  patient  has  taken  two  or  three 
inspirations-,  it  must  then  be  inflated  by  blowing  air  into  it,  and 
be  fitted  to  the  upper  end  of  the  water  chamber,  as  shown 
in  the  figure.  As  the  ether  vessel  is  turned  round  the  indicator 
traveling  from  0  to  1,  2,  3,  and  F  successively,  the  air  has  to 
traverse  the  ether  vessel  before  reaching  the  bag,  and  so  the 
patient  gets  gradually  a  more  and  more  highly  saturated  ether 
atmosphere.  Two  ounces  of  ether  are  poured  into  the  project- 
ing arm  before  the  operation,  and  these  usually  sufl&ce  for  the 
case.  The  opening  is  so  arranged  as  to  prevent  an  excessive 
quantity  being  used,  and  to  guard  against  the  possibility  of  a 
few  drops  escaping  through  the  inner  openings. 

The  ether  vessel  and  surrounding  water  chamber  are  so  ar- 
ranged that,  although  the  vapor  freely  escapes,  no  fluid  over- 
flows in  whatever  position  the  inhaler  may  be  held.  The  water 
chamber  is  centred  by  a  shaft  which  communicates  with  the 
interior  of  the  ether  receptacle,  and  the  vapor  escapes  into  this 
shaft.     From  below  a  hollow  metal  c^-linder  fitting  to  the  face- 


clover's  small  portable  ether  inhaler.      167 

piece,  and  above  shaped  like  a  clarionet  mouth-piece,  enters 
the  sliaft  and  closes  it,  being  able  at  the  same  time  to  rotate 
with  the  face-piece.  To  this  is  fixed  the  long  metal  indicator 
turned  at  right  angles  at  its  extremity.  From  above  a  similar- 
shaped  piece  of  metal  is  fixed,  so  that  the  two  "clarionet" 
pieces  are  adjacent,  the  lower  one  capable  of  rotation,  the 
upper  one  fixed.  Finall}^  the  shaft  is  completely  closed  above 
by  the  air  bag,  which  is  attached  to  a  metal  cj^inder,  closing 
but  freely  movable  in  the  shaft.     Ether  can  only  reach  the 


Plate  35. 


Fig.  0. 


Figs.  0, 1,  2,  3,  and  F 


Ether 


patient  when  the  two  "clarionet"  pieces  wholly  or  partially 
coincide.  When  the  lower  piece  moves,  the  indicator  travels 
with  it,  and  should  it  point  to  0  the  ether  way  is  blocked,  and 
then  the  patient  breathes  simply  air  through  the  shaft  in  and 
out  of  the  bag.  As  soon  as  the  indicator  is  moved  from  0  the 
' '  clarionet ' '  pieces  cease  to  shut  off  ether,  and  the  air  enters 
the  chamber  and  becomes  impregnated  with  its  vapor.  When 
F  is  reached  the  patient  is  inhaling  ether  vapor  diluted  only 
by  the  amount  of  air  exhaled  from  his  lungs.  The  following  is 
the  method  of  using  this  inhaler  :  The  appropriate  sized  face- 


168  ARTIFICIAL    ANAESTHESIA. 

piece  being  selected  and  two  ounces  of  ether  placed  in  the 
receiver,  the  air-bag  is  removed  and  the  indicator  turned  to  0. 
The  patient  is  then  directed  to  inspire  deeplj',  and  the  face- 
piece  applied  firmly  but  gently.  Uniform  pressure  is  well 
borne,  while  hard  pressure,  if  unequally  distributed,  will  not  be 
tolerated.  When  the  patient  has  taken  two  or  three  deep 
breaths,  the  air-bag  is  filled  by  the  administrator  blowing  in  air, 
and  is  placed  into  an  aperture  at  the  top  of  the  dome,  so  that 
the  patient  now  breathes  in  and  out  of  this  bag.  The  indicator 
is  now  moved  to  1,  so  that  the  patient  is  breathing  one-fourth 
ether  and  three-fourths  air,  A  few  breaths  of  such  a  dilution 
of  ether  will  accustom  the  larynx  to  the  irritating  vapor,  and 
so  obviate  coughing,  spasm,  and  the  wretched  feeling  of  suffo- 
cation which  ensues  upon  presenting  a  strong  ether  atmosphere 
to  the  patient  at  the  commencement  of  an  inhalation.  This 
tolerance  achieved,  the  indicator  is  pushed  to  2,  and  the  patient 
then  inhales  half  ether  and  half  air.  If  this  strength  of  vapor 
do  not  distress  him,  the  indicator  can  be,  after  a  few  seconds, 
carried  to  3  (one-fourth  part  air,  three  parts  ether)  and  then  to 
F  (all  ether).  The  patient  will,  in  from  ninety  seconds  to  two 
minutes  and  a  half,  be  completely  unconscious  and  ready  for 
operation.  Some  persons  require  more  ether  to  afi"ect  them, 
and  those  who  persistently  resist  taking  the  anaesthetic  by  hold- 
ing iheir  breath,  or  by  taking  the  shallowest  breaths  consistent 
with  life,  will  delay  the  onset  of  unconsciousness  much  longer. 
These  persons  also,  since  they  voluntarily  semi-asphyxiate 
themselves  by  repressing  respiratory  movements,  suffer  great 
additional  discomfort  from  the  feeling  of  suffocation  they 
induce. 

As  soon  as  complete  anaesthesia  is  thoroughly  established, 
the  indicator  may  be  brought  back  to  2,  and  there  kept  until 
the  operation  is  over.  It  may  be  necessary  in  warm  weather, 
and  in  the  case  of  prolonged  operations,  to  renew  ether  in  the 
receiver.  This  is  easily  done  by  removing  the  inhaler  from  the 
patient's  face,  loosening  the  cork,  and  pouring  in  a  further 
supply. 

The  patient  will,  during  a  prolonged  operation,  require  the 


THE    CONE    AND    ITS    MODIFICATIONS.  169 

inhaler  taken  off  his  face  every  sixth  breath  or  so,  in  order  that 
he  may  take  a  few  inspirations  of  air.  The  necessity  for  this 
will  be  readily  recognized  by  the  degree  of  cyanosis  apparent  in 
the  face,  and  by  the  character  of  the  respirations  and  the  pulse. 
It  should  be  carefully  borne  in  mind  that  the  amount  of  an  an- 
aesthetic required  to  produce  narcosis  is  much  greater  than  is 
needed  to  maintain  that  condition.  Also  the  degree  of  narcosis 
must  be  varied  in  correspondence  with  the  region  of  the  body 
upon  which  operative  measures  are  being  pursued. 

The  Cone  and  its  Modifications. 

The  cone  is  the  chief  form  in  which  ether  is  administered  as 
an  anaesthetic  in  the  United  States.  It  is  made  by  folding  a 
starched  towel,  inside  of  which  is  a  newspaper,  into  a  cone 
large  enough  to  go  over  the  mouth  and  nostrils.  The  edges 
are  rounded,  and  the  sides  pinned  together  with  catch-pins. 
In  the  apex  of  this  cone  is  placed  a  carefully  washed  sponge 
dipped  in  hot  water  and  squeezed  out  from  time  to  time  so  as  to 
prevent  freezing  of  the  watery  portions  of  the  ether.  Ether  is 
poured  on  the  sponge,  half  an  ounce  at  a  time,  and  repeated,  as 
found  necessary,  by  removing  the  cone  from  the  patient's 
mouth.  A  very  convenient  cone  has  been  found  in  the  ordi- 
nary straw  cuff,  in  which  is  fixed  a  sponge,  devised  by  a  dentist 
of  Hartford. 

Advantages  of  the  Cone  for  the  Inhalation  of 
Ether. — The  advantages  are  :  first,  the  ease  with  which  they 
are  made  and  removed  from  the  patient's  mouth  when  there 
are  signs  of  danger  ;  second,  the  simple  cone  is  never  employed 
with  a  second  patient,  which  is  a  great  advantage  in  the  way  of 
cleanliness.  All  heavy  or  complicated  inhaling  apparatus  are 
objectionable,  as  they  are  apt  to  become  unclean,  the  valves  get 
out  of  order,  and  the  patient  interfered  with  in  his  movements 
by  the  weight  of  them. 

The  chief  objections  to  the  cone  and  its  modifications  are 
that  they  allow  the  undiluted  ether  vapor  to  impinge  upon  the 
larynx,  or  the  sponge  to  become  frozen  with  wastefulness  of  the 
ether. 

12 


170 


ARTIFICIAL    ANESTHESIA. 


Plate  36. 


Dr.  Lente's  Ether  Inhaler. 

As  early  as  1866,  Dr.  Lente  invented  a  form  of  inhaler,  which 
has  recently  been  modified.  (See  Plate  36.)  The  present  im- 
proved instrument  resembles  very 
much  the  face-piece  of  "  Wal- 
denburg's  apparatus"  for  the 
inhalation  of  condensed  and  rari- 
fied  air.  The  idea  of  using  sheet 
brass  and  the  india-rubber  air- 
cushion  was  taken  from  it.  The 
air-cushion,  however,  proved  a 
failure,  and  the  inventor  sub- 
stituted hair  for  stuffing  the 
cushion,  which  he  states  retains 
sufficient  of  its  rotundity  to  fit 
the  face  air-tight. 

Mode  of  Employing  this 
Form  of  Inhaler. — A  piece  of 
sheet  lint  is  stuff'ed  into  the  cone, 
a  piece  of  wire  or  whalebone  is  slipped  in  so  as  to  keep  the  lint 
in  place  and  prevent  its  touching  the  face.  The  lint  is  satu- 
rated with  ether  and  placed  over  the  face.  There  is  an  open- 
ing, fitted  with  a  cork  stopper  at  the  apex,  large  enough  to  ad- 
mit air.  This  is  usually  closed,  but  if  it  is  found  necessary,  the 
stopper  can  be  removed.  The  ether  can  be  poured  in  at  this 
opening  without  removing  the  apparatus  from  the  patient's 
face.  Its  cleanliness  is  perfect,  as  a  different  piece  of  lint 
should  be  employed  each  time. 


Lente's  Ether  Inhaler. 


Ether  Inhalers— Modifications  of  the  Cone. 

One  of  the  same  kind  as  the  above  is  that  called  after  its  de- 
signer, Dr.  Ormsby,  of  Dublin  (Plate  37).  It  consists  of  a 
leather  face-piece  with  cushioned  rim,  provided  with  a  valve, 
which  can  be  opened  at  the  pleasure  of  the  administrator ;  at 
the  top  of  the  face-piece  is  a  cone-shaped  wire  cage,  covered 
externally  with  leather,  and  leading  into  a  soft  leather  bag, 
covered  by  a  loose  net,  which  prevents  its  undue  expansion.    In 


ETHER  INHALERS MODIFICATIONS  OF  THE  CONE.       171 


Plate  37. 


the  wire  cage  a  sponge  is  placed,  and  upon  this  an  ounce  of  ether 
is  poured.  The  apparatus  is 
applied  to  the  patient's  face, 
and  he  is  desired  to  take  a  full 
breath.  Even  when  the  valve 
is  kept  widelj"  open,  the  sense 
of  suffocation  is  so  great  (the 
rush  of  ether  vapor  producing 
more  or  less  spasm)  that  the 
patient  struggles  fiercely  to 
escape  what  appears  like  im- 
pending asphyxia. 

Should  it  be  necessary  to 
add  fresh  anaesthetic  during 
the  operation,  it  is  done  by 
pouring  ether  down  a  tube 
which  enters  the  centre  of  the 
sponge. 

Ormsby's  inhaler  is  open  to 
several  objections,  e.g.,  it  pro- 
duces great  discomfort  by  al- 
lowing undiluted  ether  vapor 
to  impinge  upon  the  larynx ; 


Ormsby's  Ether  Inhaler. 


the  sponge  is  very  liable  to  freeze  hard,  and  so  no  evaporation  of 
ether  takes  place  ;  it  occasions  great  struggling ;  it  is  wasteful 
of  the  ether.  This  apparatus  is  used  quite  extensively  both  in 
England  and  Ireland. 

Hearn's  Ether  Inlialer. 

It  is  named  after  its  inventor,  Dr.  Joseph  W.  Hearn,  of 
Philadelphia,  who  has  had  an  extended  experience  in  the  ad- 
ministration of  anaesthetics. 

The  inhaler  (Plate  38)  has  its  outer  case,  A,  made  of  thin 
sheet  metal,  having  the  lower  edge,  which  comes  in  contact 
with  the  face,  covered  with  rubber. 

Inside  of  this  case  a  screen  of  wire  gauze,  B,  is  fitted,  which 
comes  opposite  the  lower  joint,  as  at  A. 

The  lint  or  Canton  flannel  upon  which  the  ether  is  poured  is 


172 


ARTIFICIAL    ANESTHESIA. 


shown  at  C,  and  is  held  in  place  between  the  wire  gauzelscreen, 
B,  and  the  funnel-shaped  top,  D. 
The  object  of  this  inhaler  is  to  furnish  an  undiluted  ether 


Plate  38. 


SNOWOEN. 
Hearn's  Ether  Inhaler. 


vapor,  and  prevent,  as  it  should  when  ether  is  used,  the 
patient's  inhaling  the  surrounding  atmosphere.  The  time  re- 
quired to  produce  complete  anaesthesia,  in  ordinary  cases,  is 
from  five  to  eight  minutes. 


CHEATHAM  S  ETHER  INHALER. 


173 


Clieathain's  Ether  Iiilialer. 

This  operates  by  replenishing  the  evaporating  surface  with- 
out removing  it  from  the  face.  A  patient  cannot  be  etherized 
as  quickly  with  it  as  with  the  common  cone,  but  with  much  less 
ether,  and  by  it  you  avoid  the  disagreeable  effects  of  having  the 
ether  permeating  every  part  of  the  office  or  house  in  which  it 
is  used.  Its  convenience  of  application  is,  also,  quite  obvious. 
The  ease  with  which  the  face-piece  (being  paper)  can  be  re- 
moved immediately  after  use  and  thrown  away  is,  we  think,  a 
strong  recommendation  in  its  favor, 

The  apparatus  consists  of  a  tin  cup  (Plate  39,  A),  holding  in 
the  inside  a  sponge  as  an  evaporating  surface,  and  connected 
from  the  top  by  rubber  tubing  with  the  bottle  that  contains  the 
anaesthetic.  This  tube  has  attached  to  its  distal  end  a  cap,  D, 
that  will  fit  over  the  neck  of  almost  any  bottle,  thus  doing  away 
with  Lente's  graduated  bottle. 

Plate  39. 


Cheatham's  Ether  Inhaler. 


Mode  of  Using  the  Inhaler. — Make  a  cone  of  paper,  cut 
the  top  off,  so  when  the  tin  cup,  A,  is  slipped  inside  the  top  of 
the  cup  it  will  protrude  a  line  or  two  from  the  top  of  the  cone. 
Place  tin  cup,  B,  over  both  cup  and  cone,  screw  it  down  tightly 
by  means  of  nut,  C,  and  you  have  the  cone  held  tightly.  At- 
tach tube  to  top  of  cup  and  the  apparatus  is  complete.  The 
smaller  the  cone  the  more  quickly  you  can  get  the  patient  under 
the  influence  of  the  anaesthetic.     We  would  suggest,  after  the 


174 


ARTIFICIAL    ANESTHESIA. 


cone  is  in  position,  the  bottom  should  be  trimmed,  leaving  a 
part  of  it  (we  shall  call  it  the  back  part)  that  is  intended  to  go 
over  the  chin  three  inches  longer  than  the  cup,  and  sloping  for- 
wards and  upwards,  leaving  the  front  part,  intended  to  go  over 
the  nose,  about  an  inch  longer  than  the  cup.  E  gives  an  inside 
view  of  cup  A* 

Parkinson  Ether  Inhaler. 

"  In  presenting  this  apparatus  to  the  notice  of  the  profession, 
I  wish  at  the  outset  to  disclaim  any  idea  of  misappropriation. 
The  instrument  is  in  principle  identical  with  Ormsby's  inhaler, 
the  best  points  of  which  have  been  utilized.  A  practical 
experience  of  some  nine  years  with  the  original  apparatus  has 


Parkinson  Ether  Inhaler. 

A.  Inhaler  ready  for  use.  B.  Ether  reservoir.  C.  Ether  measure, 
showing  sponge  inside.  1.  Air  cushion,  inflated.  2.  Air  cap. 
3.  Wire  net  basket  to  contain  sponge.    4.  Rubber  bag  collapsed. 

induced  me  to  modify  it,  so  that  a  compact,  efficient  and  inex- 
pensive inhaler  could  be  obtained  by  any  practitioner.  The 
improvements  are  the  substitution  of  rigid,  instead  of  flexible 

*  These  various  forms  of  inhalers  can  be  had  from  the  S.  S.  White 
Co.,  Snowden,  Gemrig  or  Kolbe,  instrument  makers,  of  Philadel- 
phia; also  Geo.  Tieman  &  Co.,  of  New  York,  and  from  Codman  & 
ShurtleflF,  of  Boston. 


PARKINSON    ETHER    INHALER.  175 

metal  in  the  face-piece,  the  omission  of  the  ether  supply  tubes, 
and  the  modification  of  minor  details  throughout. 

"The  apparatus  consists  of  a  metallic  face-piece,  the  base  of 
which  corresponds  to  the  usual  facial  lines.  To  the  upper  part 
of  this  is  fastened  a  wire  net  basket,  around  the  mouth  of  which, 
and  projecting  into  the  face- piece,  is  a  small  gutter,  which  pre- 
vents ether  or  moisture  from  dropping  on  the  patient.  On 
one  side  of  the  face-piece  is  an  air  cap,  which  exposes  or  covers 
a  slot,  on  rotation.  A  collapsible  rubber  bag,  shaped  somewhat 
like  a  cranial  ice  cap,  is  attached  to  the  face-piece,  its  elastic 
neck  grasping  the  apex  of  the  latter,  where  a  groove  has  been 
made  for  its  reception.  A  rubber  air  cushion  fits  over  the  base 
of  the  face-piece,  maintaining  its  position  by  a  lip  which  forms 
part  of  the  cushion. 

"To  prepare  the  inhaler  for  use,  when  the  temperature  of 
the  room  is  below  65,  place  a  small  napkin  or  towel,  wrung  out 
of  very  hot  water,  in  the  face-piece  for  a  few  minutes.  The 
sponge,  which  should  have  an  absorption  capacity  of  two 
ounces,  is  soaked,  squeezed  dry,  and  placed  in  the  wire  net 
cone,  so  that  every  part  is  above  the  gutter.  The  air  cushion 
is  then  fitted  and  partially  inflated.  Pour  one  ounce,  by 
measure,  of  ether  on  the  sponge,  and  place  the  inhaler  on  the 
face,  with  the  air  slot  wide  open.  This  should  be  closed  after 
three  or  four  inspirations.  During  the  progress  of  an  operation, 
fresh  air  is  added,  as  required,  in  quantities  of  four  drachms. 
If  used  for  half  an  hour,  it  is  advisable  to  remove  the  sponge 
and  squeeze  out  the  moisture  which  has  formed  by  condensation. 

"The  points  of  superiority  claimed  for  this  inhaler  are,  that 
it  is  compact,  portable  and  inexpensive.  It  is  simple  in  con- 
struction, and  the  rubber  portions,  when  worn  out,  are  easily 
duplicated.  It  is  most  economical  in  the  use  of  ether,  and  the 
unpleasant  odor  of  the  drug,  by  diffusion,  is  absent.  With  it 
the  production  of  anaesthesia  is  a  certainty.  The  rapidity  of 
its  action  will  equal  any  apparatus,  and  there  is  no  method  of 
ether  administration  which  surpasses  it  in  safety. 

"Amongst  the  objections  raised  are  those  common  to  all  per- 
manent apparatus  :  that  it  is  dirty,  and  that  infective  matter  will 
adhere  to  it,  or  may  lotige  in  the  sponge.     The  simplicity  of  its 


176  ARTIFICIAL    ANESTHESIA. 

construction  admits  of  a  ready  and  perfect  cleansing ;  and  no 
part  will  be  injured  by  hot  water  or  antiseptic  solutions  which 
are  familiar  to  most  practitioners.  Against  the  inhaler  per  se 
it  is  urged  that  the  anaesthesia  partakes  largely  of  carbonic  di- 
oxide poisoning — that  this  is  a  source  of  danger,  and  an  insep- 
arable defect." 

Inhaler  of  Nitrous  Oxide  Gas  or  Etlier  of  Codnian 
&  Sliurtleff,  of  Boston. 

The  points  for  which  they  claim  superiority  are : 

1.  Durability;  being  made  of  metal,  they  are  not  liable  to 
be  easily  broken,  as  so  frequently  happens  to  the  hard-rubber 
inhalers,  and  as  they  are  nickel-plated  they  retain  their  brilliant 
polish  without  change. 

2.  For  convenience  both  to  the  patient  and  operator.  With 
one  hand,  the  latter  can  apply  the  inhaler,  and  open  or  close 
the  two-way  stopcock,  leaving  the  other  hand  at  liberty  to  con- 
trol the  patient,  or  for  such  exigencies  as  may  occur.  As  the 
elastic  hood  covers  both  nose  and  mouth,  the  patient  is  saved 
the  necessity  of  having  the  nostrils  closed  either  by  clamps  or 
the  fingers — a  part  of  the  operation  always  very  disagreeable, 
and  to  very  sensitive  patients  positively  frightful,  as  it  produces 
a  feeling  of  suffocation. 

3.  Cleanliness.  The  rubber  hood,  which  alone  comes  in 
contact  with  the  face,  is  easily  removed  and  replaced ;  and  as 
all  the  other  parts  are  either  metal  or  hard  rubber,  the  whole 
instrument  can  be  kept  perfectly  pure  by  washing,  which  is  a 
point  of  great  importance  to  the  comfort  of  the  patient. 

4.  Durability  and  accurate  working  of  the  valves.  Upon 
this,  perhaps,  more  than  anything  else,  depends  the  successful 
administration  of  anaesthetics.  If  the  exhaling  valve  does  not 
quickly  and  perfectly  close  while  the  gas  is  being  inhaled,  air 
is  taken  in  with  it,  and  the  gas  is  so  much  diluted  that  it  very 
much  delays,  or  wholly  prevents,  the  desired  effect. 

If,  on  the  other  hand,  the  inhaling  valve  does  not  work  prop- 
erly, the  patient  breathes  back  into  the  reservoir  a  mixture  of 
nitrous  oxide  and  air. 


CODMAN    <fc    SHURTLEFF  S    INHALER. 


177 


Plate  41  is  the  inhaler,  with  a  hard  rubber  mouth-piece,  A ; 
the  metal  hood,  B,  is  used  for  nitrous  oxide  gas. 


Plate  41. 


COOMAN    &    SMURTLEFF, 
BOSTON. 


Plate  42  is  the  inhaler  for  nitrous  oxide  gas.     A,  metallic 
hood,  containing  B,  flexible  rubber  hood,  covering  both  nose 


and  mouth ;  C,  exhaling  valve ;  D,  two-way  stop-cock ;  I,  pack- 
ing, through  which  a  silk  cord  passes ;  E,  sliding-joint,  where 
J  is  detached  to  connect  the  ether  reservoir ;  J  contains  the  in- 
haling valve. 

Plate  43,  the  inhaler  arranged  for  using  ether.  This  differs 
from  Plate  42  only  in  the  addition  of  the  hollow  sphere,  F, 
which  contains  a  coarse  sponge,  on  which  the  ether  is  poured 
through  the  opening,  Gr ;  H,  cover  closing  the  reservoir  when 
not  in  use.  This  part  is  attached  at  the  sliding-joint,  E,  and 
will  fit  most  inhalers  made  by  Codman  &  Shurtleff  during  the 
last  three  years.     By  this  arrangement,  waste  of  ether  byevap- 


178 


Artificial  anesthesia. 


orating  is  prevented,  and  it  is  stated  that  less  than  half  the 
quantity  is  required  to  produce  or  keep  up  anaesthesia. 


The  operator  also  escapes  breathing  so  much  of  the  ether,  as 
he  is  compelled  to  do  when  using  it  from  a  sponge  or  napkin. 

The  Souchon  Auxiliary  Injector  for  the  Uninter- 
rupted Anaesthesia  in  Operations  upon 
the  Face  and  Mouth.* 

"All  surgeons  know  the  trouble,  anxiety,  and  danger  of  oper- 
ating upon  the  face  and  mouth  on  account  of  the  necessity  of 
removing  the  face-piece  through  which  the  anaesthetic  is  admin- 
istered so  as  to  uncover  the  field  of  operation  and  enable  the 
operator  to  proceed ;  soon  after  the  removal  of  the  face-piece 
the  patient  recovers  from  the  effects  of  the  anaesthetic  and  the 
operator  has  to  stop  for  the  face-piece  to  be  reapplied  ;  and  so 
on  during  the  whole  of  the  operation.  All  these  drawbacks 
and  delays  become  very  much  worse  when  the  patient  happens 
to  be  one  of  those  unfortunates  who  respond  badly  to  the  eiFects 
of  the  anaesthetic,  or  who  often  wake  up  quickly  from  a  deep 

*  Eead  at  the  meeting  of  the  Southern  Surgical  and  Gynaecological 
Association,  at  Washington,  D.  C,  on  November  12,  1895,  by  Edmond 
Souchon,  M,D.,  of  New  Orleans,  La. ;  Professor  of  Anatomy  and  Clin- 
ical Surgery,  Tulane  University,  Fellow  of  the  American  Surgical 
Association.     Abstract  from  The  Medical  News,  November  23,  1895. 


THE    SOUCHON    AUXILIARY    INJECTOR.  179 

anaesthesia  and  become  almost  unmanageable.  It  is  a  very 
sorry  sight,  that  of  an  operation  half  completed,  and  an  unruly 
patient  bleeding  freely  and  spurting  blood  all  around  by  the  wild 
movements  of  his  head.  His  life  is  then  at  stake  from  the 
impossibility  of  completely  controlling  the  haemorrhage  all  the 
while  and  of  completing  the  operation  in  time. 

"It has  been  my  ill-luck  to  have  once  encountered  such  a  case, 
and  the  impression  was  such  as  to  make  me  determine  that 
henceforth  I  would  control  my  patient  by  safe  and  uninterrupted 
anaesthesia.  Junker's  inhaler  is  not  equal  to  such  emergencies, 
because,  unless  the  bulb  is  pressed  very  gently,  the  liquid 
anaesthetic  is  forced  into  the  pharynx,  I  therefore  devised  an 
apparatus  to  that  end,  reducing  the  pain,  the  bleeding,  the 
shock,  and  the  duration  of  the  operation  to  a  minimum. 

"The  apparatus  was  called  the  Ancesthetizer  or  Ancesthetic 
Injector.  Its  feature  was  that  neither  the  inlet-tube  nor  the 
outlet-tube  dipped  into  the  liquid,  so  that  it  was  impossible  for 
any  liquid  anaesthetic  to  be  injected  into  the  patient's  pharynx. 
But  its  drawback  was  that  ether  alone  could  not  be  used, 
because  it  was  too  freely  diluted  with  air  to  have  a  thorough 
anaesthetic  effect.  Besides,  the  mixture  of  air  and  chloroform 
was  also  rather  diluted,  and,  should  a  particularly  refractory  case 
present  itself,  there  was  no  positive  means  of  increasing  the 
strength  of  the  dilution  at  will  and  as  necessity  required.  These 
inconveniences  have  been  overcome  in  the  new,  improved  appa- 
ratus. It  is  an  injector,  truly,  and  not  an  inhaler  as  we  under- 
stand it. 

"  In  this  apparatus  the  inlet-tube  dips  into  the  liquid  so  that 
the  air  in  passing  out  through  the  outlet-tube  is  much  more 
charged  with  the  vapors  of  the  ansesthetic.  But  here  at  once 
with  this  dipping  of  the  inlet-tube  came  two  difficulties :  first, 
upon  releasing  the  compression  on  the  bulb,  the  liquid  was 
aspirated  into  the  bulb ;  and,  second,  the  liquid  anaesthetic  was 
thrown  through  the  outlet-tube  into  the  patient's  pharjmx.  It 
required  the  utmost  care  and  gentleness  to  avoid  these  accidents, 
and  there  were  cases  in  which  the  full  power  of  the  apparatus 
had  to  be  brought  to  bear  to  maintain  the  patient  uninterruptedly 
anaesthetized." 


180  ARTIFICIAL    ANESTHESIA. 

These  difficulties  have  been  conquered,  and  they  have  been 
by  placing  a  proper  valve  on  the  course  of  the  inlet-tube,  and 
by  maintaining  a  certain  distance  between  the  level  of  the  liquid 
in  the  bottle  and  the  point  of  exit  of  the  fixed  brass  portion  of 
the, outlet- tube.  The  distance  must  not  be  more  than  one-half 
of  the  height  of  the  receptacle.  It  took  much  experimenting 
and  close  observation  before  this  was  found  out.  Diaphragms, 
perforated  tubes,  etc. ,  were  used,  but  in  vain,  as  they  all  failed 
when  the  liquid  exceeded  a  certain  amount.  Now,  a  certain 
quantity  is  necessary,  otherwise  it  would  compel  a  too  frequent 
replenishing.  Of  course,  the  size  of  the  rubber  bulb  is  an  im- 
portant factor ;  if  too  small,  it  would  not  inject  a  sufficient 
amount  of  the  anaesthetic  ;  if  too  large,  it  produced  such  a 
splashing  in  the  bottle  as  to  require  but  a  small  amount  of 
liquid ;  otherwise,  if  too  much,  the  liquid  would  be  injected 
into  the  pharynx. 

The  bulb  is  7J  inches  in  circumference  at  its  middle.  The 
size  of  the  bottle  is  also  to  be  considered ;  it  is  6i  inches  in  cir- 
cumference or  If  inches  in  diameter.  Therefore,  the  size  of  the 
bottle  and  of  the  bulb,  the  amount  of  liquid  in  the  bottle,  to- 
gether with  the  distance  of  the  surface  of  the  liquid  from  the 
brass  and  fixed  orifice  of  the  outlet-tube,  are  the  correlative 
factors. 

Description  of  Apparatus. — The  present  improved  appa- 
ratus is  considered  perfect  in  all  particulars.  It  is  composed  of 
a  glass  cylindric  receptacle,  with  a  frame  supporting  a  ring  for 
the  thumb  and  a  rubber  bulb,  so  that  it  can  be  worked  with  one 
hand.  From  the  bulb  originates  a  rubber  tube,  wrapped  with 
coiled  wire  to  prevent  it  from  bending ;  it  ends  in  the  inlet- 
tube  ;  just  at  the  point  of  junction  is  a  ball-valve,  which  pre- 
vents the  liquid  from  entering  the  bulb  when  the  pressure  upon 
the  latter  is  released.  The  inlet-tube  extends  through  the 
liquid  anaesthetic  to  the  very  bottom  ;  its  lower  end  is  bevelled 
to  prevent  the  orifice  from  being  stopped  by  coming  in  contact 
with  the  bottom  of  the  receptacle. 

This  inlet-tube  slides  up  and  down  through  another  shorter 
tube,  so  that  it  can  be  drawn  well  up  above  the  level  of  the 
liquid  anaesthetic,   thereby  diminishing  the  strength   of  the 


THE    SOUCHON    AUXILIARY    INJECTOR.  181 

vapors  injected  through  the  outlet-tube  into  the  pharynx. 
This  feature  makes  the  apparatus  thus  set  an  anaesthetizer  of 
the  first  model. 

There  is  a  circular  line  on  the  receptacle  showing  how  much, 
and  no  more,  liquid  anaesthetic  should  be  poured  in  without 
running  the  risk  of  injecting  liquid  through  the  outlet-tube. 
This  line  corresponds  to  the  middle  of  the  receptacle  from  the 
bottom  to  the  upper  surface  of  the  lid.  This  quantity  will  suf- 
fice to  keep  a  patient  anaesthetized  for  nearly  two  hours  with 
chloroform  alone,  one  hour  and  a  half  with  a  mixture  of  equal 
parts  of  chloroform  and  ether,  and  about  an  hour  with  ether 
alone.  The  receptacle  is  closed  by  a  metallic  lid  that  screws 
around  its  neck ;  a  washer  makes  it  air-tight. 

From  this  lid  springs  the  metallic  portion  of  the  outlet-tube  ; 
it  originates  directly  from  the  under  surface  of  the  lid  ;  it  is  j 
inch  in  diameter  inside  and  li  inches  in  height;  after  a  very 
sharp  curve  of  90°  it  terminates  by  an  orifice  of  not  less  than  ^ 
inch.  Repeated  experiments  have  determined  these  dimen- 
sions ;  any  decrease  in  them  increases  the  chances  of  sputtering 
and  of  injecting  liquid  into  the  throat. 

To  this  metalHc  portion  is  attached  a  rubber  tube  30  inches 
long,  so  that  the  anaesthetist  can  hold  himself  well  out  of  the 
way  of  the  operator,  leaving  more  room  and  play  for  those 
directly  concerned  in  the  operation.  This  tube  should  be  suffi- 
ciently rigid  not  to  bend  too  easily ;  its  interior  diameter  should 
be  -^  inch.  Its  last  eight  inches  are  formed  by  an  ordinary 
rubber  catheter,  No.  13  English,  connected  to  the  main  tube 
by  a  piece  of  glass  or  metallic  tubing ;  this  nasal  segment  can 
be  changed  to  a  smaller  one  when  operating  upon  children.  It 
is  provided  with  a  clasp,  seven  inches  from  the  extremity ;  this 
clasps  the  nostrils  and  holds  the  tube  in  proper  position.  The 
receptacle  is  readily  emptied  through  the  outlet-tube  after  the 
operation  is  over. 

The  lid  is  provided  with  a  funnel,  through  which  the  anaes- 
thetic is  poured  into  the  receptacle,  and  through  which  it  can 
also  be  emptied  after  being  used.  To  the  edge  of  the  funnel 
is  adapted  a  clasp  with  a  long  arm,  that  answers  for  a  hook  by 
which  the  apparatus  can  be  suspended  from  a  buttonhole  ;  the 


182  ARTIFICIAL    ANESTHESIA. 

clasp  is  to  catch  on  to  the  cloth  of  the  gown  when  there  is  no 
button-hole  for  the  hook.  Thus  the  anaesthetist  may  have  both 
hands  free,  resting  or  helping  for  a  while. 

Modus  Operandi. — When  the  apparatus  is  to  be  used  it  is 
first  filled  with  the  aneesthetic  up  to  the  circular  line ;  that 
represents  2i  ounces.  The  nasal  end  of  the  tube  is  smeared 
with  vaselin.  If  desirable,  an  aseptic  thin  towel  in  a  single 
thickness  can  be  thrown  over  the  apparatus  without  interfering 
with  the  proper  working. 

After  the  patient  has  been  thoroughly  anaesthetized  by  any 
of  the  ordinary  methods,  the  face-piece  is  removed,  the  tube 
is  introduced  through  the  nose  until  the  clasp  is  reached,  a  dis- 
tance of  7  inches,  and  the  clasp  is  made  to  grasp  the  nostril 
and  fix  the  tube ;  the  end  of  the  tube  is  then  in  the  lower 
pharynx ;  that  is  necessary,  because,  if  too  high  up,  the  patient, 
breathing  through  the  mouth,  would  not  inhale  a  sufiicient 
amount  of  the  anaesthetic. 

The  anaesthetist  places  himself  to  one  side  or  other  of  the 
middle  of  the  patient,  so  as  to  feel  the  radial  pulse,  observe  the 
respiration,  and  be  well  out  of  the  way  of  the  operator  and  his 
assistants.  By  compressing  the  bulb  the  apparatus  is  set  to 
work.  It  injects  only  the  vapor,  and  no  liquid  anaesthetic  into 
the  pharynx,  regardless  of  the  force  used  on  the  hulb.  The  bulb, 
however,  should  be  compressed  gradually,  not  jerkingly,  speci- 
ally if  it  causes  coughing  or  recoil  of  the  patient.  By  com- 
pressing the  bulb  more  or  less  quickly  and  thoroughly  the 
amount  of  anaesthetic  is  graduated.  As  much  as  possible  the 
compression  should  take  place  at  the  time  of  each  inspiration. 
This  rule  compels  a  closer  watch  on  the  respiration. 

It  takes  very  little  anassthetic  to  maintain  anaesthesia  when  a 
patient  has  already  been  well  anaesthetized.  It  is  important 
not  to  keep  on  compressing  the  bulb  if  the  patient  does  not  re- 
quire it,  or  if  the  stage  or  procedure  of  the  operation  is  not 
painful.  Much  harm  is  often  produced  by  all  methods  by  un- 
necessarily prolonged  deep  anaesthesia,  which  harm  is  often 
passed  under  the  name  of  shock,  exhaustion,  etc. 

At  times,  when  the  patient  expires,  a  resistance  is  felt  upon 
pressing  the  bulb ;  of  course,  all  force  on  the  bulb  should  be 


THE    SOUCHON    AUXILIARY    INJECTOR.  183 

suspended  until  it  is  felt  that  the  resistance  has  yielded  and  the 
patient  is  about  to  inspire. 

Anesthesia  with  Chloroform  Alone. — When  chloro- 
form alone  is  used  the  eflfects  are,  at  their  best,  quick  and 
thorough.  Greater  care  should  be  exercised  when  chloroform 
is  used  alone.  It  is  then  that  it  would  perhaps  be  prudent  to 
draw  the  inlet-tube  up  above  the  level  of  the  liquid  ;  the  dilu- 
tion is  then  diminished. 

Mixture  of  Chloroform  and  Ether. — The  mixture  of 
equal  parts  of  chloroform  and  ether  is  the  one  I  prefer.  It  has 
the  advantage  of  the  quick  and  thorough  effects  of  chloroform 
and  the  stimulating  action  of  the  ether. 

Anaesthesia  with  Ether  Alone. — The  use  of  ether  alone 
in  the  apparatus  at  first  excites  the  throat  if  the  patient  bas 
been  chloroformed,  but  this  soon  passes  off,  and  aneesthesia  is 
well  maintained  throughout  the  operation.  Of  course,  those 
patients  who  yield  with  difficulty  to  the  ordinary  method  of 
angesthetization  will  be  more  troublesome  with  ether.  It  re- 
quires more  ether,  more  complete  and  frequent  compressions  of 
the  bulb,  and  a  closer  observation  of  the  inspirations  than  when 
chloroform  alone  is  used.  We  should  remember,  however, 
that  ether,  especially  if  used  alone,  is  contraindicated  in  opera- 
tions about  the  face,  head  and  neck,  because  of  the  great  con- 
gestion which  it  usually  produces. 

Proportions  of  Anesthetic  Yapor  and  Air. — Mr.  Her- 
mann Fleck,  Ph.D.,  Instructor  of  Chemistry  in  the  Harrison 
Chemical  Laboratory  of  the  University  of  Pennsylvania,  was 
kind  enough  to  determine  the  proportions  of  anaesthetic  vapors 
and  air  at  each  compression  of  the  bulb.  When  the  tube  is 
above  the  level  of  the  cMoroform  the  expelled  air  contains  8.2 
per  cent,  of  vapor  ;  when  the  tube  extends  through  the  chloro- 
form, the  expelled  air  contains  11.9  per  cent,  of  vapor,  or  about 
one-third  more.  When  the  tube  is  above  the  level  of  the  ether ^ 
the  expelled  air  contains  18  per  cent,  of  vapor  ;  when  the  tube 
extends  through  the  ether  the  expelled  air  contains  37.2  per 
cent.,  or  double  the  quantity.  It  is  noticeable  that  the  expelled 
air  is  much  more  charged,  about  three  times  more,  by  passing 
through  ether  than  when  passing  through  chloroform,  and  only 


184  ARTIFICIAL    ANAESTHESIA. 

about  twice  when  the  tube  does  not  extend  into  the  anaesthetic. 
In  all  cases,  of  course,  the  dilution,  after  it  passes  from  the  out- 
let tube  and  is  inhaled,  is  from  four  to  six  times  weaker. 

Sundry  Remarks. — The  amount  of  anaesthetic  consumed  is 
very  small,  about  1  ounce  of  chloroform  per  hour,  but  2J  ounces 
of  ether  for  the  same  length  of  time.  There  is  no  external 
evaporation,  and  this  will  be  greatly  appreciated  by  the  opera- 
tor and  his  assistants. 

The  apparatus  works  very  well  also  when  the  head  is  lowered, 
as  in  the  Rose  position. 

Should  the  operation  involve  the  two  nasal  cavities  at  the 
same  time  when  the  tube  might  be  in  the  way,  the  tube  could 
be  introduced  through  the  mouth  into  the  lower  pharynx,  care 
being  taken  to  prevent  the  tube  being  bitten  by  using  a  wedge 
or  gag,  or  by  connecting  the  end  with  a  metallic  tube,  or,  best, 
with  a  disinfected  male  metallic  catheter,  which  the  teeth  could 
not  crush. 

The  end  of  the  flexible  tube  may  be  connected  with  the  apex 
of  the  face-piece  or  cone  placed  over  the  mouth  and  nose  and 
the  vapor  of  the  anaesthetic  forced  into  it.  But  the  face-piece 
must  fit  tightly  and  exclude  the  air,  because  the  air  from  the 
bulb  has  already  diluted  the  chloroform.  For  that  reason  ether 
used  thus  very  seldom  produces  anaesthesia. 

Anaesthesia  maj''  be  produced  from  the  outset  without  pre- 
viously using  a  face-piece  by  introducing  the  tube  at  once 
through  the  nose  into  the  lower  pharynx.  This  does  away  with 
all  possible  nasal  reflexes,  the  eff"ects  of  which  have  been  so 
graphically  demonstrated  by  Professor  Laborde,  the  successor 
of  Claude  Bernard  and  Paul  Bert  at  the  College  de  France,  in 
Paris. 

The  lower  end  of  the  bulb  is  so  arranged  as  to  allow  it  to  be 
connected  with  a  piece  of  tubing  leading  to  a  bag  of  oxygen,  if 
desired. 

For  obvious  reasons  it  is  important  that  all  connections  should 
be  air  tight. 

Care  should  be  taken  that  no  bends  or  kinks  form  in  any  part 
of  the  tubes,  or  this  will  interfere  with  the  proper  working  of 
the  apparatus. 


THE    SOUCHON    AUXILIARY    INJECTOR.  185 

Sometimes  the  little  ball-valve  in  the  tube  becomes  adherent 
to  the  margin  of  the  orifice  inside  and  the  bulb  does  not  empty; 
by  striking  on  the  tube  at  that  point  the  valve  becomes  loose 
again. 

The  bulb  is  detachable  and  may  be  removed  whenever  this 
becomes  necessary,  that  is,  when  it  loses  its  firmness  and  elas- 
ticity, and  when  the  valves  get  out  of  order.  This  is  deter- 
mined by  pressing  tightly  the  tube  of  the  bulb,  and  compress- 
ing the  bulb ;  if  the  air  is  then  expelled  it  is  because  the  valves 
are  out  of  order.  The  manufacturer  can  supply  a  new  bulb  by 
mail. 

Ever}'  part  of  the  apparatus  can  be  taken  apart  to  be  thor- 
oughly cleaned  and  sterilized. 

The  apparatus  is  most  useful  also  in  operations  about  the 
head  and  neck,  allowing  the  operator  and  his  assistants  more 
room,  and  sparing  to  all  around  the  unpleasant  odor  of  the 
anaesthetic. 

The  device  has  been  used  in  the  Charity  Hospital  of  New 
Orleans  by  about  all  the  surgeons,  Drs.  Matas,  Delaup,  Martin, 
Bloch,  etc.,  also  by  Dr.  DeRoaldes  in  the  Sanitarium.  I  have 
used  it  for  Dr.  Lange,  in  New  York,  in  the  presence  of  Drs. 
Halsted  and  Fenger,  and  in  the  Jefferson  Clinic,  in  Philadel- 
phia, for  Drs.  Keen  and  Hearn,  in  the  presence  of  Drs.  Da 
Oosta  and  Barton.  All  these  surgeons  expressed  themselves 
well  pleased  with  the  results. 

No  ill  effects  have  ever  resulted  from  the  direct  contact  of  the 
vapors  of  the  anassthetic  with  the  mucous  membrane  of  the 
pharynx  or  larynx. 

Conclusions. — This  apparatus  is  the  only  one  with  which 
there  is  no  risk  of  injecting  liquid  anaesthetic  in  the  phai^nx  re- 
gardless of  the  force  applied  to  the  hidh.  Its  safety,  simplicity, 
compactness,  portability,  efi&ciency  and  easy  management  speak 
for  themselves. 

Its  use  results  in  a  great  saving  of  time,  pain,  bleeding  and 
shock  to  the  patient,  thereby  contributing  materiallj^  to  the 
saving  of  life  in  operations  which,  for  the  most  part,  are  long 
and  bloody,  and  often  bring  the  patient  to  death's  door.  It 
also  provides  a  great  saving  of  mental  strain  to  the  surgeon, 

1  o 


186  ARTIFICIAL    ANESTHESIA. 

who  can  proceed  rapidl3'^  and  uninterruptedly  with  the  opera- 
tion. 

Abstract  of  a  Lettefr  froyn  Dr.  Marion  Souchon,  Son  of  the 

Inventor. 

"  New  Orleans,  July  20,  1896. 

"Concerning  the  use  of  the  instrument  in  regard  to  after- 
effects, I  have  witnessed  its  use  more  than  a  dozen  times,  fol- 
lowed the  cases,  and  failed  to  see  any  incidental  complications. 
As  stated  in  brief,  the  apparatus  has  been  used  by  all  the  sur- 
geons here  ;  also  by  Dr.  DeRoaldes,  Chief  Surgeon  of  the  Eye, 
Ear,  Nose  and  Throat  Hospital. 

"I  could  not  say  whether  the  doctor  has  any  data  relative  to 
experiments  asked,  and  I  regret  it,  for  I  feel  confident  of  its 
favorable  comparison  with  other  such  devices. ' ' 

On  Tissue  Cliang-es  Found  i^  Cases  of  Secondary 
Death  After  Ether. 

In  a  series  of  carefully-conducted  experiments  by  Prof  H.  C. 
Wood  and  Dr.  WilHam  S.  Carter,  chiefly  on  dogs,  and  a  post- 
mortem of  an  adult  female  who  was  supposed  to  have  died 
from  the  effects  of  ether,  after  the  removal  of  an  ovary  con- 
taining a  papillomatous  cj^st,  about  ten  fluid  ounces  of  ether 
were  used.  Consciousness  was  regained  in  the  ordinary  length 
of  time  ;  there  was  no  pain,  but  the  patient  complained,  when 
spoken  to,  of  "feeling  so  tired  and  weak."  The  urine  was 
examined  before  the  operation  and  was  found  normal  in  specific 
gravity  and  free  from  albumin.  There  was,  however,  a  family 
history  of  tuberculosis — all  the  members  of  which  were  dead, 
except  herself. 

We  have  not  space  for  a  full  detail,  but  state  that  the  proto- 
plasm was  found  turbid  and  granular.  In  the  muscle  of  the 
diaphragm  the  fibrous  layer  had  lost  their  striation,  and  had  a 
granular  appearance  with  pigmenting  infiltration  distributed 
irregularly  through  the  protoplasm,  which  is  unquestionably 
granules  of  fat. 

Kidneys. — There  was  an  excess  of  connecting  tissue.    Several 


DEATH    AFTER    RETURN    TO    CONSCIOUSNESS.       187 

of  the  glomeruli  show  hyaline  degeneration  in  the  tufts  of  cap- 
illaries and  the  capsule  of  Bowman. 

To  sum  up,  the  condition  found  microscopicall}'  was  brown 
atrophy,  with  cloudy  swelling  of  heart ;  cloudy  swelling  and  fatty 
degeneration  of  kidnej^s,  which  showed  some  chronic  disinte- 
grated changes,  fatty  degeneration  and  brown  atrophy  of  muscle 
of  diaphragm. 

The  following  were  a  few  of  the  conclusions : 

That  chloroform  always  produces  a  much  more  profound  dis- 
turbance of  metabolism,  which  is  more  apt  to  cause  death  than 
ether. 

That  although  the  tissue  changes  found  in  cases  of  secondary 
death  after  ether  or  chloroform  are  alike  in  character,  and  maj'^ 
be  about  equal  in  intensity  when  the  two  agents  are  given  in 
poisonous  doses  for  the  same  length  of  time,  on  one  or  upon 
successive  daj's,  and  not  followed  by  death,  the  tissue  changes 
caused  by  chloroform  are  much  more  serious  than  those  pro- 
duced by  ether. 

In  dogs,  invariably,  the  straight  tubules  of  the  kidneys  were 
most  affected.  Cloudy  swelling  ;  disappearance  of  muscle  ; 
striated  granular  degeneration  ;  the  occasional  appearance  of 
hyaline  and  of  fatty  degeneration. 

These  valuable  experiments  will  require  confirmation  more 
especially  in  cases  in  which  the  individual's  family  had  not 
suffered  from  hereditary  disease. 

Is  It  Possible  to  Have  Death  Produced  by  an 

Anaesthetic  Some  Time  After  the  Cessation 

of  the  Administration  and  the  Retiu-n 

of  Consciousness  ? 

The  following  are  the  conclusions  of  Drs.  Wood  and  Carter:* 
The  conclusions  which  have  been  reached  by  the  series  of  ex- 
periments recorded  in  the  present  memoir  are  : 

First. — That  lowered  arterial  pressure  has  a  comparatively 
feeble  effect  upon  the  respiration  and  upon  the  vaso-motor  sys- 

*  From  an  original  essay  in  manuscript  kindly  loaned  to  the  author 
by  Dr.  H.  C.  Wood. 


188  ARTIFICIAL    ANAESTHESIA. 

tern,  and  that  that  effect  is  distinctly  stimulating  rather  than 
depressing,  unless,  indeed,  the  imperfect  supply  of  blood  to  the 
respirator}"  and  vaso-motor  centres  be  continued  so  long  as  to 
impair  their  nutrition. 

Second. — The  circulation  recovers  itself  more  slowly  after 
profound  etherization  than  after  a  like  chloroform  narcosis. 

Third. — That  it  is  possible  for  an  anaesthetic  to  produce 
death  some  hours  after  the  cessation  of  its  administration  at  a 
time  when  the  cerebrum  has  long  freed  itself  from  distinct  evi- 
dences of  the  narcotic,  so  that  consciousness  and  intellectual 
action  have  been  restored. 

Fourth. — That  prolonged  etherization,  as  well  as  prolonged 
chloroformization,  produce  serious  structural  changes  in  various 
organs  of  the  body ;  that  this  occurs  in  the  lower  animals  and 
in  man  ;  a  comparison  of  our  results  upon  dogs  and  the  lesions 
found  in  the  body  of  man  (B). 

Case  of  Miss  B.  shows  a  uniformity  of  change,  unless  it  be  in 
the  fact  that  in  the  dogs  invariably  the  straight  tubules  of  the 
kidney  were  more  affected  than  were  the  convoluted  tubules  ; 
whereas,  in  the  case  of  Miss  B.  the  convoluted  tubules  were  more 
affected  than  the  straight  tubules.  Cloudy  swelling,  disappear- 
ance of  muscle-striae,  granular  degeneration,  the  occasional  ap- 
pearance of  hyaline  change  and  of  fatty  degeneration,  were, 
however,  the  marked  features  in  all  the  cases. 

Fifth. — That  in  many  cases  the  amount  of  tissue  change 
found  after  a  secondary  death  from  ether  or  chloroform  does 
not  seem  to  be  sufficient  to  have  produced  the  death  by  simple 
arrest  of  the  functions  of  the  organs,  although  it  is  impossible 
to  decide  accurately  how  far  the  partial  failure  of  function  of 
many  vital  organs  may  work  together  to  bring  about  the  fatal 
result.  It  is  possible  that  in  the  disturbance  of  nutrition,  sec- 
ondary poisoning  may  be  produced  which  may  have  deleterious 
effects  upon  the  general  nervous  system.  At  present,  however, 
the  only  established  facts  are  the  administration  of  the  anaes- 
thetic :  nutritive  changes  produced  by  that  anaesthetic,  ending 
in  distinct  structural  alteration  and  death.  It  cannot,  at  this 
time,  be  determined  whether  the  death  is  attributable  to  the 
alteration  of  structure,  or  whether  it  is  due  to  some  secondary 


DEATH    AFTER    RETURN    TO    CONSCIOUSNESS.       189 

poisoning;  the  matter  is  not,  however,  of  practical  import,  the 
ether  or  the  chloroform  under  anj-  circumstances  being  the 
cause  of  death . 

Sixth. — That  in  cases  of  secondar}'  death,  after  ether  and 
chloroform,  the  structural  changes  are  similar  in  character  and 
may  be  equal  in  intensity;  but  after  narcosis  of  a  certain  dura- 
tion— say  one  hour — from  ether,  the  changes  in  the  tissue  are 
not  nearly  so  great  as  will  be  found  after  a  narcosis  of  the  same 
duration,  one  hour,  produced  by  chloroform  ;  and  that  there- 
fore chloroform  is  much  the  more  active  agent  in  the  production 
of  structural  lesions — a  conclusion  which  is  confirmed  by  the 
fact,  which  has  been  very  apparent  in  our  researches,  namely, 
that  secondary  deaths  in  animals  occur  very  much  more  fre- 
quently after  chloroform  than  after  ether. 

In  applying  these  conclusions  to  the  subject  of  practical  an- 
aesthesia, it  is  evident  that,  contrary  to  what  seem  to  be  d  priori 
probable,  the  depression  of  the  circulation  produced  by  chloro- 
form has  little  or  no  direct  effect  upon  the  respiratory  centres  ; 
and  that  the  failure  of  respiration,  which  occurs  during  chloro- 
formization,  must  be  solely  due  to  the  direct  influence  exercised 
by  the  drug  upon  the  respiratory  centres.  Failure  of  respira- 
tion, undoubtedly,  profoundly  affects  the  heart,  but  the  relation 
between  the  two  functions  does  not  seem  to  be  reciprocal ;  so 
that  the  fact  that  ether  stimulates  the  circulation  does  not,  so 
far  as  the  respiratory  centres  are  concerned,  give  it  any  superi- 
ority over  chloroform. 

Clinical  experience  shows  that  nausea  and  general  depression 
are  more  pronounced  after  the  use  of  ether  than  after  the  use 
of  chloroform,  a  difference  which  is  strongly  insisted  upon  by  the 
advocates  of  chloroform  as  an  important  agent  in  favor  of  that 
anaesthetic.  Our  research  confirms  clinical  observation,  and 
experimentallj"  shows  that  the  depression  of  the  circulation 
produced  by  ether  is  more  permanent  than  that  caused  by 
chloroform,  the  reason  probably  being  the  large  amount  of  ether 
which  is  necessary  to  produce  profound  narcosis  with  lowering 
of  the  arterial  pressure,  an  amount  so  large  that  it  can  neither 
be  burned  up  in  the  sj^stem  nor  yet  eliminated  in  the  time  which 
would  be  necessary  for  the  much  smaller  amount  of  chloroform 
to  be  gotten  rid  of  after  chloroformization. 


190  ARTIFICIAL    ANESTHESIA. 

An  important  result  of  our  labors  is  the  demonstration  of  the 
fact  that  anaesthetics  may  produce  death  in  the  animal,  and, 
therefore,  certainly  in  man,  at  a  time  when  the  ordinary  effects 
of  the  anaesthetic  have  disappeared,  and  that  in  the  bodies  of 
human  beings  and  animals  widespread  structural  lesions  are  to 
be  found.  It  would  seem  from  our  experiments,  in  conjunction 
with  those  previously  performed  with  chloroform  by  other  ob- 
servers, that  during  ether  and  chloroform  narcosis  there  is 
always  interference  with  the  nutrition  of  the  protoplasm 
throughout  the  body.  Ordinarily  this  interference  is  not  suffi- 
cient to  produce  permanent  structural  lesions  ;  the  cloudy  swell- 
ing subsiding,  the  protoplasm  regains  its  normal  condition. 
The  fact  of  the  change  is,  however,  very  important,  as  indicat- 
ing that  anaesthetics  produce  much  more  effect  than  is  usually 
supposed,  and  the  incautious  use  of  them  for  every  trivial  ope- 
ration is  not  praiseworthy.  Local  anaesthesia  certainly  should 
be  used  by  the  surgeon  whenever  it  is  applicable. 

The  question  as  to  the  effect  of  previous  health  upon  the 
effect  of  anaesthetics  on  the  general  tissues  is  most  important. 
At  present  we  have  no  way  of  deciding  in  any  case  whether  the 
tissues  of  the  individual  will  or  will  not  resist  the  nutritional 
changes  of  ether  or  of  chloroform.  Certainly,  however,  there  are 
great  differences  in  different  individuals.  In  the  animal  a  pre-, 
vious  narcosis  notably  weakens  the  resistive  power  of  the  tis- 
sues. It  is  a  matter  of  great  interest  that  Miss  B.  came  of  a 
family  the  members  of  which  were  all  dead,  except  herself,  of 
tuberculosis.  The  essential  heredity  of  such  a  family  is  lack  of 
vital  resistance  to  the  tubercular  bacillus,  and  it  is  possible  that 
there  is  also  a  lack  of  vital  resistance  to  various  morbific  agents. 
The  slight  brown  atrophy  of  the  heart,  and  the  slight  cirrhosis 
of  the  kidney,  neither  of  which  had  ever  manifested  itself  at 
all  during  life,  may  possibly  have  also  impaired  the  general 
tissue  resistance. 

Our  researches  throw  light  upon  the  question  which  must 
forcibly  present  itself  continually  to  every  practical  surgeon : 
Which  is  the  safer  anaesthetic  for  prolonged  use  ?  It  is  true 
that  the  condition  of  depression  lasts  longer  after  ether,  and  that 
therefore  chloroform  would  seem  preferable ;  but  on  the  other 
hand  we  demonstrated  that  chloroform  is  much  more  active  in 


DANGER    FROM    ADMINISTRATION    PER    RECTUM.       191 

producing  structural  change  than  is  ether,  and  that  the  dangers 
of  what  we  call  "secondary  death  "  are  greater  after  chloroform 
than  after  ether. 

It  is  now  generally  acknowledged  that  the  danger  of  sudden 
death  during  the  period  of  anaesthetic  unconsciousness  is  much 
greater  from  chloroform  than  from  ether.  We  believe  that  we 
have  proven  that  the  after  dangers,  from  chloroform  are  much 
greater  than  from  ether,  and  that  in  the  question  of  immediate 
result  when  it  is  desired  to  produce  prolonged  anaesthesia,  ether 
should  always  be  preferred  to  chloroform. 

Etlier  by  tlie  Rectum. 

The  advantages  which  are  still  claimed  for  ether  by  the  rectum 
are  as  follows:  It  avoids  the  first  and  chief  danger  to  the  respi- 
ration, the  production  of  stertor,  and  the  falling  back  of  the 
jaw  and  tongue.  Second  danger.  It  avoids  the  irritating  influ- 
ence of  ether  upon  the  mucous  membrane  of  the  throat  and 
air-passages,  first  shown  by  croupy  respiration  and  flow  of 
frothy  mucus.  Third.  It  prevents  a  dangerous  complication, 
tetanic  setting  of  the  inspiratory  muscles  of  the  chest ;  no  air 
enters ;  respiration  with  the  diaphragm  fails  to  fill  the  lungs, 
and  the  patient  dies,  as  in  true  tetanus.  Fourth.  It  prevents 
simple  exhaustion,  another  source  of  danger,  as  the  patient  can 
take  nourishment,  before  the  operation,  to  sustain  the  system. 
Death  is  not  so  apt  to  occur  from  slowly-failing  respiration  when 
the  ether  is  employed  by  the  rectum.  Fifth.  It  avoids  the  dis- 
tressing and  exhausting  vomiting  and  lasting  nausea  which  is  so 
disastrous  in  abdominal  section,  in  operations  for  hernia,  and 
sections  of  the  cornea  and  iris. 

The  Chief  Danger  froiu  the  Aclniinlstration  of 
Ether  per  Rectum. 

The  chief  danger  from  the  administration  of  ether  per  rectum 
has  been  found,  as  has  been  shown  in  the  report  of  cases,  first, 
the  overdistension  of  the  bowels  with  the  ether  vapor,  or  the 
tenesmus,  with  bloody  discharges  from  the  rectum,  caused  by 
fluid  ether  being  forced  through  the  tube  and  deposited  in  con- 


192 


ARTIFICIAL    ANESTHESIA. 


tact  with  the  mucous  membrane,  producing  freezing  of  the 
parts  and  secondary  inflammation  and  ulceration.  Experiments 
have  demonstrated  that  the  cool  rubber  tubing  which  has  been 
emplo3^ed  had  a  tendency,  unless  kept  warm  by  wrapping  with 
cotton  or  felt,  to  produce  a  rapid  condensation  of  the  vapor 
driven  over  into  the  ether,  which  boils  by  the  simple  heat  of  the 
hand,  or  93°  or  96°  F.  The  temperature  of  the  water-bath 
should  not  exceed  103°  or  105°  F.    If  the  temperature  is  allowed 

Plate  44. 


C.  Lentz.  Phila. 


to  rise  to  120°  or  130°  F.,  the  boiling  becomes  so  active  as  to 
drive  over  fluid  ether. 

In  a  few  rare  operations  the  vapor  of  ether  per  rectum  may 
be  employed  with  advantage,  as  in  cases  of  excision  of  the  supe- 
rior maxilla.  It  has  been  found  that  the  administration  of  the 
ether  by  the  rectum  in  operations  on  the  superior  maxilla  was 
satisfactory.  The  patient  becomes  profoundly  anaesthetized, 
and  the  anaesthesia  is  continued  for  some  time.  The  patient 
comes  out  from  under  the  influence  of  ether  with  less  subsequent 
annoyance  than  usually  follows  the  administration  of  this  anaes- 
thetic.    Dr.  L.  A.  Stimson  devised  an  instrument  for  this  oper- 


INTERNAL    ADMINISTRATION    OF    ETHER.  193 

ation,  consisting  of  a  tube  about  the  size  of  a  No.  40  urethral 
catheter,  surrounded  at  one  end  with  a  large  sponge  with  a 
rubber  coating,  which,  when  passed  into  the  pharynx,  prevents 
the  flow  of  blood  in  that  direction  while  the  patient  breathes 
through  the  tube. 

In  abdominal  surgery,  or  if  there  be  marked  intestinal  lesion, 
this  mode  is  contraindicated. 

Its  inapplicability  in  cases  of  accident  and  emergency,  when 
time  cannot  be  allowed  to  prepare  the  bowel,  has  already  been 
mentioned. 

Other  points  of  advantage  and  disadvantage  may  occur  in 
later  experience,  and  to  other  observers,  and  new  dangers  may 
be  discovered;  but  we  are  convinced  that  this  method  is 
worthy  of  further  trial,  and  will  find  its  place  in  surgery,  ful- 
filling its  own,  though  not  all,  indications.  Like  all  else  in 
therapeutics,  it  must  pass  through  the  stages  of  bungling  use, 
condemnation  and  revival. 

Dr.  Miller's  form  of  apparatus,  see  Plate  44,  which  was 
made  for  this  purpose,  consists  simply  of  a  water-bath,  a  grad- 
uated bottle  provided  with  a  funnel  and  valve  for  pouring  in 
the  ether,  and  a  supply-pipe  for  conducting  vapor  to  the  rec- 
tum. This  tube  terminated  in  a  straight  recurrent  catheter, 
the  exhaust  channel  of  which  is  controlled  by  a  valve.  The 
catheter  is  furthermore  provided  with  a  movable  collar  for 
pressure  against  the  anus,  it  having  been  found  that  the  vapor 
tends  to  escape  by  the  tube. 

Internal  Administration  of  Etlier. 

Exhibited  internally,  ether  is  an  excellent  diffusible  stimu- 
lant. It  sinks  in  water,  and  is  best  administered  mixed  with 
spermaceti  and  sugar,  or  in  mucilage  of  gum  arable  ;  its  taste 
is  hot,  pungent  and  irritating,  and  when  placed  in  the  mouth, 
ears,  nose  or  rectum  pain  is  produced.  It  dissolves  in  alcohol, 
whiskey  or  brandy ;  and  when  required  as  a  powerful  stimu- 
lant, as  in  fainting,  exhaustion  or  collapse,  this  is  an  excellent 
method  for  administering  it.  In  using  it  for  some  time,  it  is 
best  given  enclosed  in  capsules. 


194  ARTIFICIAL    ANAESTHESIA. 

Gout. — In  sudden  attacks  of  gout  in  the  stomach  or  intes- 
tines a  useful  mixture  is  the  following : 

^     Spiritus  vini  gallici, 

Ether,         .        .         .     .  aa        .        .        .       fSj.    ^l. 
SiG. — Dose,  one  teaspoonful  in  sugar  and  ice  water,  repeated  until 
relief  is  afforded. 

This  same  preparation  will  be  found  valuable  in  spasm  of  the 
stomach,  or  intestines,  or  heart.  Ether  has  been  proved  useful 
in  tape-worm,  alone,  or  combined  with  the  oleo-resin  of  the 
male  fern.  The  patient  must  live  upon  milk  and  a  little  bread 
for  one  day,  and  the  following  morning,  fasting,  take  the  full 
dose: 

I^    Oleo  resinse  filicis, Sss. 

Ether, fSj. 

Mucilag.  acacise,  ad.  ft.,     .        .        .        .        f5ss.     M. 

This  is  to  be  repeated  in  three  hours  ;  in  the  evening  food 
can  be  taken,  to  be  followed  with  a  full  dose  of  castor  oil  with 
twenty  drops  of  spirits  of  turpentine.  Some  French  authori- 
ties prefer  to  give  f  ^iss.  of  5ther  alone,  administered  at  once, 
and  followed  in  two  hours  by  the  purgative. 

Ether  is  also  one  of  our  most  potent  remedies  in  hysteria, 
especially  when  associated  with  valerian,  asafoetida,  musk  or 
camphor.     In  the  first  with  the  fluid  extracts,  as  follows : 

^     Ether, 

Valerian,  ex.  fluid,     .        .        aa        .        .      fSj.    M. 
SiG. — A  teaspoonful  every  hour. 

In  the  second  it  is  mixed  with  the  tinctures  as  follows : 

^    Ether, 

Tinct.  Asafcetidse,  .        .        .     aa        .        .      2j. 

Mucilag.  acacite, 5j.     M. 

SiG. — A  teaspoonful  every  hour  until  relieved. 


ETHER-SPRAY    IN    POST-PARTUM    HEMORRHAGE.       195 

With  musk : 

^    Moschus,     . 3ij. 

Ether, 

Mucilag.  acacise,         .        .    aa        .        .         fSj.    M. 
SiG. — A  teaspoonful  every  hour. 

With  camphor,  ether  is  not  only  useful  in  hysteria,  but  all 
forms  of  ' '  nervousness^ ' '  in  dysmenorrhoea^  diarrhoea^  cholera^ 
dbnormal  sexual  excitement^  epilepsy^  hysterical,  puerperal  and 
strychnic  convidsions.  Camphor  with  ether  is  best  administered 
as  follows  : 

I?*    Vitelli  ovi, Sij. 

Pulv.  camphorse, 5ij. 

Ether,  .......         Sij.    M. 

Add  the  ether  to  the  camphor,  and  then  the  emulsion ;  administer 
in  tablespoonful  doses  every  two  hours. 

Treatment  of  Sciatica  by  Subcutaneous  Injection 

of  Ether. 

Fifteen  drops  was  first  given,  which  was  followed  immediately 
by  great  relief  from  the  pain,  and  soon  passed  off.  The 
injection,  in  increasing  doses  up  to  thirty  drops,  was  repeated 
morning  and  evening  for  three  days,  when  the  patient  was  dis- 
charged cured.  No  local  injury  resulted ;  the  injections  were 
made  in  the  ordinary  superficial  method,  and  not  deep. 

Astlima. 

Inhalation  of  ether  is  very  valuable  in  relieving  spasmodic 
asthma,  and  obtaining  sleep  for  the  patient.  It  can  be  em- 
ployed alone,  or  associated  with  the  tincture  of  digitalis,  conium 
or  opium.  The  ordinary  dose  of  the  ether  is  from  ten  to  forty 
minims,  and  of  the  tincture  of  digitalis  or  opium  from  ten  to 
thirty  minims. 

The  Ether- Spray  in  Post-partum  Hgemorrhag-e. 

The  use  of  ether-spray  in  post-partum  haemorrhage  has  been 
sometimes   successful  in  cases  in  which  the  usual  means  of 


196  ARTIFICIAL    ANESTHESIA. 

arresting  the  flow  had  been  resorted  to  without  effect.  The 
spray  is  directed  on  the  abdominal  walls,  along  the  spine  and 
over  the  genitals. 

Coryza  and  Obstinate  Hoarseness. 

Drs.  Chapman  and  Physick  recommended  the  vapor  of  equal 
parts  of  Hoffman's  anodyne  or  compound  spirits  of  sulphuric 
ether,  with  equal  parts  of  laudanum,  in  cases  of  recent  catarrh, 
in  coryza  and  obstinate  hoarseness,  by  inhalation.* 

Ether  as  an  Expectorant. 

Ether  has  been  found  useful  as  an  expectorant  in  the  sub- 
acute or  chronic  form  of  bronchitis.  It  is  a  valuable  remedy, 
and  is  prescribed  in  five  and  ten-minim  doses,  on  a  little  sugar, 
every  three  or  four  hours,  or  it  can  be  taken  by  inhalation,  as 
follows  :  The  cork  of  a  bottle,  half-filled  with  ether,  is  perfo- 
rated by  two  glass  tubes,  neither  being  immersed  in  the  ether. 
A  few  inspirations  through  the  tubes  every  hour  or  two  is 
sufficient.  As  the  remedy  is  also  a  diuretic  and  diaphoretic,  its 
utility  is  thereby  increased. 

Chorea. 

A  jet  or  hand  spray  of  sulphuric  ether,  free  from  alcohol, 
applied  to  the  spine  will  relieve  the  most  violent  spasmodic  or 
convulsive  attack  of  chorea,  with  the  subsequent  use  of  Fowl- 
er's solution,  five  to  ten  drops  three  times  a  day  in  water,  and 
occasional  application  of  the  galvanic  current  to  the  spine. 

IN^ervous  Aphonia,  or  Temporary  Loss  of  Voice. 

The  vapor  of  ether  is  a  most  valuable  remedy  in  hysterical 
or  nervous  loss  of  voice.  It  has  been  the  means  of  discovering 
malignerers,  who  were  supposed  to  be  deaf  and  dumb,  and  who, 
as  soon  as  they  came  under  its  anaesthetic  influence,  were  able 
both  to  hear  and  speak. 

*  We  have  also  employed  one-quarter  grain  of  sulphate  of  morphia 
in  the  place  of  the  laudanum,  making  a  more  elegant  preparation, 
and  with  good  success. 


ETHER    INTOXICATION.  197 

Diphtheritic  Ang^ina,  or  Pseudo-Membranous 

Croup. 

Cases  of  diphtheritic  angina  have  been  treated  with  success 
by  inhalations  of  ether  and  steam,  with  the  internal  use  of 
brandy,  calomel,  etc. 

Whooping'-Cough, 

Ether  alone  by  inhalation  is  extremely  useful  in  the  relief  of 
whooping-cough  ;  and  a  combination  of  ether  sixty  parts,  chlo- 
roform thirty  parts,  and  oil  of  turpentine  or  tar  one  part,  has 
been  found  a  successful  remedy.  The  patient  should  be  con- 
fined to  his  room,  and  at  every  access  of  coughing  use  a  por- 
tion in  an  inhaler. 

Ether  Intoxication. 

A  few  years  ago  there  was  published*  "The  Confessions  of 
an  Ether  Inhaler,"  a  member  of  our  own  profession,  for  whom 
it  subsequently  became  necessary  to  sign  a  certificate  of  insanity. 

Dr.  Ewald,  of  Berlin,  reports  a  somewhat  similar  case.  It  is 
that  of  a  man  aged  thirty-two,  who  was  admitted  into  the 
Charite  Hospital,  under  Professor  Frerich,  sufiering  from  gen- 
eral debility  and  trembling  of  the  muscles.  On  inquiry,  it  was 
found  that  he  was  notorious  in  Berlin  for  intoxicating  himself 
with  ether,  his  abuse  of  which  had  reduced  him  to  his  present 
miserable  condition.  He  was  originally  temperate,  and  had  been 
a  university  student,  passing  all  his  examinations  with  credit ; 
he  was,  however,  of  a  mystical  turn  of  mind.  Unfortunately, 
a  little  more  than  nine  years  ago,  there  fell  into  his  hands  a 
medico-popular  treatise,  in  which  the  use  and  eff'ects  of  ether, 
used  medicinally,  were  described,  and  a  glowing  account  was 
given  of  its  effect  in  quickening  the  creative  power  of  the  mind. 
He  procured  about  two  or  two  and  a  half  ounces  of  sulphuric 
ether,  and  inhaled  it  from  a  handkerchief  ;  the  result  being  to 
produce  insensibility  for  about  a  quarter  of  an  hour,  during 
which  time  he  imagined  that  he  lived  for  an  indefinite  time,  and 
travelled  over  whole  worlds.  This  condition,  however,  he  was 
not  again  able  to  induce  in  so  high  a  degree.     Becoming  grad- 

*  Medical  and  Surgical  Eeporter. 


198  ARTIFICIAL    ANESTHESIA. 

ually  more  and  more  addicted  to  his  habit,  he  no  longer  con- 
fined himself  to  indulging  himself  in  his  own  room,  but  with 
his  etherized  handkerchief  before  his  face,  he  wandered  through 
the  streets,  purchasing  small  quantities  of  ether  at  the  drug- 
gists' shops,  until,  at  last,  he  became  so  great  a  nuisance  to 
them  that  many  of  them  closed  their  doors  against  him.  He 
was  also  turned  out  of  his  lodgings,  on  account  of  the  annoy- 
ance produced  by  the  smell  of  his  breath,  and  became  a  house- 
less wanderer,  reduced  in  means  and  in  health.  In  the  hospital 
there  was  no  indication  that  his  mind  was  affected  ;  his  memory 
was  not  impaired  ;  his  style  of  speaking  was  fluent.  On  one 
occasion  an  attempt  was  made  to  produce  complete  anaesthesia. 
For  this  purpose  more  than  seven  ounces  were  required  ;  the 
ether  being  given  by  an  inhaler,  and  loss  being  prevented  by 
closing  in  the  apparatus  with  cotton-wood.  No  sooner,  how- 
ever, was  the  inhalation  stopped,  than  the  state  of  insensibility 
passed  off.  He  was  then  allowed  to  take  the  ether  in  his  own 
way,  by  inhaling  it  from  a  handkerchief.  Given  in  this  way,  it 
produced  a  stage  of  excitement,  during  which  he  danced  about 
the  room,  talked  nonsense,  and  appeared  much  pleased,  but 
there  was  no  true  narcotism.  It  was  not  thought  justifiable  to 
subject  him  to  othei-  experiments  with  ether,  as  it  was  desirable 
to  break  through  his  habit.  It  is  interesting  that  his  suscepti- 
bility to  the  action  of  cannabis  indica  was  not  impaired.  This 
drug  was  given  as  a  substitute  for  ether,  and  on  the  first  occa- 
sion, too  large  a  dose  having  been  given,  the  result  was  the  pro- 
duction of  phantasms,  such  as  are  induced  by  the  smoking  of 
hasheesh. 

The  late  Dr.  Morgan,  of  Dublin,  states  that  ether  is  em- 
ployed in  certain  portions  of  Ireland  as  a  substitute  for 
whiskey.* 

A  case  has  come  under  the  writer's  notice  in  which  a  patient 
began  the  use  of  sulphuric  ether  in  teaspoonful  doses  as  a  ner- 
vine ordered  by  a  physician,  and  ultimately  increased  the  dose 
to  one  pint  per  da}^  When  informed  of  its  injurious  character, 
she  had  lost  her  appetite,  and  suffered  gastric  disturbance  ;  she 

*  In  Ireland  and  Eussia  a  law  has  been  recently  passed  forbidding 
the  public  sale  of  ether  unless  ordered  by  a  regular  physician. 


ETHER    INTOXICATION.  199 

gradualh'  diminished  the  quantity,  and  was  able  to  ^ive  it  up 
after  a  month  or  two.  The  onl}-  effect  it  had  upon  her  was  to 
give  her  apparent  strength  to  go  on  with  her  teaching  of  music. 
Large  quantities  of  etlier  have  been  taken  internally,  and,  so 
far  as  we  have  been  able  to  learn,  no  death  has  j^et  occurred 
from  its  use  in  this  way. 

Chronic  Intoxication  from  Ether. "^ — I'he  patient,  a 
woman  of  48  years,  had  been  in  the  habit  of  swallowing  after 
€ach  meal  a  lump  of  sugar  wetted  with  sulphuric  ether  to  re- 
lieve a  difficulty  in  digestion.  During  the  space  of  two  months 
and  a  half  preceding  her  admission  to  the  hospital  de  La  Pltie^ 
she  took,  in  this  manner,  a  total  of  180  grammes  (nearly  six 
ounces).  When  she  had  continued  the  practice  for  about  seven 
weeks,  trembling  of  the  hands  commenced.  A  week  later  she 
began  to  feel  severe  pains  in  the  lower  front  part  of  the  chest, 
and  between  the  shoulder  blades.  She  also  suffered  from  vom- 
iting of  a  whitish  watery  fluid  on  rising  in  the  morning.  In  a 
week  more  her  gait  became  unsteady,  and  she  suffered  from 
trembling  of  the  toes,  cramps  in  the  calves,  and  prickling  sen- 
sations in  the  feet. 

Upon  admission  to  the  hospital  she  presented  all  the  above 
symptoms.  The  pain  resembled  that  which  would  be  caused 
by  two  blisters  of  eight  or  ten  centimetres  in  diameter,  the  one 
placed  a  little  above  the  epigastrium,  the  other  at  the  same 
level  on  the  back.  It  was  intermittent,  and  was  excited  by  any 
sort  of  ailment.  There  were  regular  slight  twitchings  in  cer- 
tain portions  of  the  limbs.  The  strength  of  the  hands  was  not 
diminished.  Almost  continual  buzzing  in  the  ears ;  muscae 
volitantes  occasionally,  usually  followed  by  a  brief  attack  of 
frontal  headache.  Pupils  slightly  enlarged.  Sleep  undisturbed. 
No  fever.  Soft  souffle  at  base  of  heart  and  in  vessels  of  neck, 
accompanying  the  first  sound.     No  other  important  symptoms. 

An  emetic  at  entrance,  a  daily  bath,  a  little  opium  at  night, 
and  abstinence  from  ether,  constituted  the  entire  treatment. 
Kecovery  was  complete  at  the  end  of  two  weeks. 

"'••  Martin.     Gazette  des  Hopitaujc,  May  10,  1870. 


200  ARTIFICIAL    ANAESTHESIA. 

Vivisections. 

An  excellent  use  of  ether  may  be  made  in  regard  to  animal 
vivisections.  Ether  enables  us  to  lull  the  sensibilities  of  the 
victim,  tranquilly  pursue  the  natural  workings  of  the  internal 
organs,  and  the  changes  which  take  place  from  experimental 
applications  ;  while  the  student  of  surgery  can  accustom  himself 
to  those  gushes  of  the  vital  fluid,  which,  in  the  human  body, 
are  viewed  with  so  much  terror  by  the  unpracticed.  Animals 
of  any  size  may  be  etherized  in  a  box,  or  by  covering  the  head 
with  an  India-rubber  sack,  into  which  a  mixture  of  ether  and 
atmospheric  air  is  forced. 

Vivisections  witli  Etlier  and  Cliloruforni. 

Prof  Schiff,  of  Geneva,  states:  "In  our  experiments,  that 
is,  in  more  than  three  thousand  cases,  we  have  adopted  etheri- 
zation with  a  view  to  preserve  the  life  of  animals ;  and  that, 
with  few  exceptions,  indicated  elsewhere  (Memoir  on  the  Laryn- 
geal Nerve),  not  a  single  case  of  death  occurred.  On  the  other 
hand,  chloroform  has  cost  us  a  considerable  number  of  animals 
when  I  have  wished  to  push  anesthesia  to  its  ultimate  stage." 

In  our  experiments  we  have  proven  that  even  bromide  of 
ethyl  is  safer  in  making  vivisections  than  chloroform. 


CHAPTER    VL 


Ethers  which  have  Anaesthetic  Properties — Acetic  Ether — Experi- 
ments by  Dr.  H.  C.  Wood  on  Animals,  etc. — Formic  Ether — Hy- 
driodic  Ether — Properties  and  Objections  to  its  Use — Mythlic 
Ether — Dr.  Eichardson's  Experiments  with  It— Bichloride  of 
Methylene— Observations  upon  It  by  Dr.  Buxton  and  Spencer 
Wells,  of  London— Ethyl  Iodide— Ethylene  Bromide— Iodoform 
—Carbon  Dichloride—Bromoform— Tetrachloride  of  Carbon- 
Butyl  Chloride— Chloride  and  Bichloride  of  Ethylene- Iodide  of 
Methyl — Amylene — Chloral  Hydrate — Acetic  Aldehyde. 

Acetic  Etlier  (C2H6C2H3O2). 

Acetic  ether  is  colorless,  and  has  an  agreeable  odor  and  burn- 
ing taste.     Specific  gravity,  0.89;  boiling-point,  165.2°  F.     If 


METHYLIC    ETHER.  201 

kept  in  contact  "with  air,  and  in  the  presence  of  water,  free 
acetic  acid  is  formed.  According  to  Dr.  H.  C.  Wood,  in 
pigeons  and  rabbits  it  produces  perfect  unconsciousness  without 
as  much  previous  struggling  as  when  sulphuric  ether  is  used, 
and  has  the  advantage  over  that  compound  of  being  less  in- 
flammable ;  on  the  other  hand,  its  volatility  is  less.  In  experi- 
menting with  this  ether  we  must  use  caution. 

Formic  Etlier  (C2H5CHO2). 

Formic  ether  is  a  colorless  liquid,  recalling  the  odor  of  rum, 
and  having  an  agreeable  taste.  Specific  gravity,  0.915  ;  den- 
sity, 62.8;  boiling-point.  127. 3°  F.  It  dissolves  in  nine  parts 
of  water,  and  all  proportions  in  alcohol,  ether,  fixed  and  vola- 
tile oils.  It  has  been  found  that  this  ether  decomposed  into 
alcohol  and  alkaline  forminates  by  the  alkalies  of  the  blood. 
When  inhaled,  it  lowers  the  temperature  and  induces  asphyxia. 

Hydi-ioclic  Ether  (C2HJ). 

Hydriodic  ether  is  a  colorless,  non-inflammable  liquid,  having 
a  peculiar  etheral  odor  and  taste,  soluble  in  alcohol  and  nearly 
insoluble  in  water.  It  boils  at  1 58. 5°  F.  ;  specific  gravity  of 
liquid  at  32°,  1.9755.  Exposed  to  the  air  and  light,  it  liberates 
iodine  and  becomes  brown,  which  irritates  the  nostrils  and  causes 
lachrymation,  and  is  sometimes  employed  by  inhalation  to  bring 
the  system  under  the  influence  of  iodine  in  chronic  bronchitis 
and  phthisis. 

Methylic  Etlier  (CH3)02— Methyl  or  Bichloride, 
So  called  by  Klchardson. 

Mixture  of  1  vol.  methyl  alcohol  and  4  vols,  chloroform. 

Methylic  ether  is  a  colorless  and  very  inflammable  gas,  heavier 
than  air,  of  an  oppressive  odor.  (In  specific  gravity,  boiling- 
point,  etc.,  we  have  followed  Prof  William  x\llen  Miller.)  It 
is  soluble  in  water,  wood-spirit,  alcohol  and  ether.  A  saturated 
solution  in  ether,  at  32°  F. ,  has  been  recommended  by  Dr.  B. 
W.  Richardson,  who  experimented  upon  himself,  and  found 
that  there  was  no  preliminary  spasm  excited  in  the  larynx,  or 

14 


202  ARTIFICIAL    ANAESTHESIA. 

elsewhere.  The  pulse  arose  to  96,  and  the  anaesthesia  was  per- 
fect, yet  he  objected  to  it  because  it  rapidlj"^  volatilizes  from  its 
solution  and  on  account  of  its  unpleasant  odor.  Dr.  Carter 
says:  "  In  Dr.  Richardson's  own  hands  I  have  seen  the  various 
(new)  ethers  act  perfectly  well,  producing  complete  unconscious- 
ness and  relaxation  of  muscle  without  either  struggling  or  sick- 
ness, and  without  unpleasant  symptoms  of  any  kind ;  but  I 
cannot  judge  how  far  such  results  may  have  been  due  to  the 
qualities  of  the  agent  employed,  how  far  due  to  specially  skilful 
or  careful  administration,  or  how  far  to  the  state  of  the  patients 
themselves." 

Bichloride  of  Methylene  (CH2OI2)— An  Anaesthetic. 

Preparation. — By  acting  oa  chloroform  with  nascent  hy- 
drogen. 

CHCI3  X  H2  =  CH.CI^  X  HCI. 

Boiling-point,  40°  C  (104°  R ). 

Methyl  and  Methylene  are  two  terms  which,  with  their 
affixes,  are  hopelessly  confusing  to  the  practitioner.  Rival 
manufacturers,  eager  to  obtain  predominant  recognition,  so 
manipulate  terms,  that  it  is  almost  hopeless  to  get  reliable  clini- 
cal reports  from  the  action  of  these  various,  but  more  or  less 
similar,  agents.  A  little  explanation  of  each  may  not  be  out 
of  place  here.  "  Methyl  blue  "  is  an  anodyne  and  anaesthetic, 
considerably  employed  with  some  success  in  the  treatment  of 
diphtheria — mixture  of  2  parts  and  98  parts  sugar.  "Methyl, 
dahlia  or  Paris  violet"  is  pyoktanin  plus,  the  new  antiseptic. 

Characters  of  Bichloride  of  Methylene. — A  colorless, 
volatile  liquid  with  smell  like  chloroform. 

Action. — Like  that  of  chloroform,  but  more  rapid,  though 
a  larger  quantity  is  required.  It  depresses  the  action  of  the 
heart  more  than  chloroform,  and  death  is  even  more  sudden 
and  without  warning  symptoms. 

This  anaesthetic  was  carefully  studied  by  Dr.  Richardson,  who 
gave  it  a  very  high  character.  This  was  in  1867.  His  views 
were  soon  called  in  question  by  Nusbaum  in  Germany,  and 
Tourdes.  Hept  and  Pean  in  France,  while  Spencer  Wells  took 


BICHLORIDE    OF    METHYLENE.  203 

up  the  subject  and  defended  it  in  England.  For  years  it  was 
fully  tested  at  Moorfields  Ophthalmic  Hospital ;  but  two 
deaths  occurred  without  any  indication  of  danger  from  the  state 
of  the  pulse  or  heart.  In  1876  we  had  it  prepared  by  Dr.  W. 
H.  Greene,  and  even  with  all  his  care  the  specimen  contained 
chloroform.  It  was  then  tested  by  us  and  the  late  Dr.  Wash- 
ington Atlee,  the  article  having  been  obtained  through  Spencer 
Wells  ;  but  Atlee  did  not  find  it  as  satisfactory  in  ovariotomy 
as  his  mixture  of  ether  and  chloroform.  Subsequently  more 
deaths  occurred  from  its  use.  Spencer  Wells  stated  at  the 
meeting  of  the  British  Medical  Association,  1877:  "  Whatever 
may  be  its  chemical  composition,  whether  it  is  chloroform 
mixed  with  some  spirit  of  ether,  or  whether  it  is  really  bichlo- 
ride of  methylene,  I  am  still  content  with  the  effects  of  the 
liquid  sold  under  that  name." 

Commercial  methylene,  obtained  through  agents  accredited 
by  Sir  Spencer  Wells,  and  therefore  considered  genuine,  was  a 
mechanical  mixture  composed  of  four  parts  of  chloroform  and 
one  of  methylic  alcohol.  In  some  comparative  experiments 
they  administered  the  two  agents,  finding  that  while  the  com- 
mercial agent  behaved  precisely  like  chloroform,  the  genuine 
methylene  bichloride  produced  choreiform  and  epileptiform 
convulsions. 

Mode  of  Preparation. — Bichloride  of  methylene  is  pre- 
pared by  heating  one  part  of  methylic  alcohol,  two  parts  of 
common  salt  and  three  parts  of  sulphuric  acid,  and  passing  the 
gas  through  water  into  a  glass  globe,  into  which  chlorine  gas  is 
conducted  at  the  same  time.  The  globe  is  drawn  out  below  so 
as  to  form  a  thin  tube,  which  passes  into  one  tubulure  of  Wolf's 
bottle,  the  second  tubulure  being  connected  by  means  of  a  bent 
glass  tube  with  a  second  Wolf's  bottle,  this  second  bottle  being 
placed  in  ice  ;  the  other  tubulure  of  this  second  bottle  is  con- 
nected with  a  flask  cooled  by  means  of  a  freezing  mixture.  The 
liquid  which  is  condensed  in  the  Wolf's  bottles  is  chiefly  chlo- 
roform, while  that  in  the  flask  is  almost  pure  meth^'lene  dichlo- 
ride,  or  bichloride  of  meth5'lene. 

A  mixture  of  chloroform  and  ether  is  sold  as  bichloride  of 
methylene.  On  shaking  this  mixture  with  water,  the  chloro- 
form is  separated  and  sinks. 


204  ARTIFICIAL    ANESTHESIA. 

Dr.  Dudley  Buxton  writes  :  "I  believe  I  am  accurate  in  say- 
ing Sir  Spencer  Wells  obtains  his  methylene  from  only  one 
source,  and  I  am  unaware  that  it  is  to  be  got  elsewhere  in 
England.  The  methylene  so  obtained  was  tested  clinically,  and 
found  to  produce  the  usual  anaesthetic  trance.  It  was  then 
submitted  to  chemical  analysis,  and  a  result  obtained  which 
showed  it  to  be  composed  of  four  parts  methylated  chloroform 
diluted  by  one  part  of  methylic  alcohol.  Subsequently  these 
investigators  prepared  some  genuine  bichloride  of  methylene 
(C2H2CI2)  which  they  administered  to  animals,  with  the  result 
that  no  anaesthesia  appeared,  but  in  its  place  wild  excitement, 
convulsions  and  death, ' ' 

Ethylene  Bromide,    (^ot  Ethyl  Bromide.)   (Dibrom- 
ethane.)     (C2H42  -=  Brg  —  CHjBr.r.) 

Lightly  brownish  liquid  ;  chloroform  odor ;  specific  gravity, 
2.189;  15°  C;  misc.  in  all  proportions.  Boils  129-131.5°  C. 
It  must  not  be  confounded  with  ethjd  bromide,  as  it  is  a  cardiac 
poison,  anti-epileptic  and  powerful  sedative. 

Uses. — It  is  employed  in  epilepsy,  delirium  tremens,  nervous 
headache  and  nervous  insomnia. 

Dose.— 1-2  ^  (0-06—0-12  Ce)  ter  a  day  in  emulsion  of 
gum  arabic  or  almonds  or  in  capsules.  Caution — poisonous 
(Merck,  in  sealed  tubes). 

Ethylene  Chlorhydrin. 

(Glycol  Chlorhydrin  ;  Mono-chlor-ethyl  Alcohol.) 

Ethylene  chloride  (not  ethyl  chloride) ;  dichlor-ethane ; 
Dutch  liquid.  C2H,Ch2  =  CH^ClCh^Ch.  C.  Thin,  oily  Hquid  ; 
pleasant  odor ;  sweet  taste  ;  irritating  vapor ;  specific  gravity, 
1.26  at  15°  C.  ;  soluble  in  alcohol,  ether  and  chloroform; 
shghtly  soluble  in  water  ;  boils  83.7°;  anaesthetic,  rubefacient ; 
antispasmodic,  anaesthethic  in  the  place  of  chloroform  ;  expec- 
torant ;  useful  in  cramps,  diarrhoea  ;  externally,  rheumatism 
and  neuralgia. 

Carbon  Dichlorine  or  Chloric  Ether 

Has  been  used  to  a  suflScient  extent  to  indicate  that  it  produces 
distinct  cardiac  depression. 


BROMOFORM.  205 

Broiuol'orm, 

Which  possesses  undoubted  anaesthetic  properties,  was  found 
in  experiments  of  Dr.  Reichart,  1889-90,  to  powerfully  depress 
the  heart,  and  in  one  experiment  on  a  small  dog  the  intrave- 
nous injection  of  thirty  minims  of  the  preparation  caused  imme- 
diate cardiac  jyrest.  Consequently,  it  was  considered  useless 
to  pursue  any  further  investigation  in  this  line.  This  is  also 
a  dangerous  impurity  of  bromide  of  ethyl. 

It  is  employed  in  the  treatment  of  whooping-cough,  although 
"for  several  months  the  only  treatment  in  our  clinic  for 
whooping-cough  has  been  bromoform.  The  method  of  admin- 
istration has  been  to  prescribe  one  or  two  drachms  pure,  and 
give  one  to  four  drops  in  a  teaspoonful  of  milk  three  to  five 
times  a  day,  according  to  age  and  severity  of  disease,  and, 
moreover,  to  give  special  instructions  that  the  Jast  remnant  be 
given  from  a  spoon,  as  bromoform  does  not  mix,  but  sinks  to 
the  bottom.     A  happy  feature  is  its  sweetness. 

"Being  entirely  ignorant  of  its  physiological  effects,  Hke  all 
of  us,  I  determined  to  'try  it  on  the  dog  first,'  as  some  of  us 
must.  FeeKng  in  perfect  health,  I  took  an  initial  dose  of  ten 
drops  ;  no  perceptible  effects.  In  one  hour,  fifteen  drops  more  ; 
nothing  experienced  in  regard  to  respiration,  pulse  or  tempera- 
ture, but  slight  swimming  sensation  in  head.  In  another  hour, 
another  dose  of  fifteen  drops ;  pulse  slightly  slowed,  tempera- 
ture and  respiration  normal,  expectoration  free  and  liquid. 
Very  dizzy  in  head  and  somewhat  nauseated,  and  general  feel- 
ing of  malaise,  all  of  which  was  very  transitory,  so  that  in  one 
hour  I  felt  as  well  as  before.  The  first  sweet  taste  of  the  drug 
lasted  but  a  very  short  time,  giving  way  to  a  burning  sensation 
of  the  tongue,  which  became  very  severe,  such  as  capsicum 
produces.  Food  had  no  taste,  and  the  throat  reflex  was  entirely 
abolished,  so  much  so  that  after  twelve  hours  the  index  finger 
could  explore  the  entire  fauces  without  the  least  unpleasant 
sensation.  I  felt  more  of  those  structures  digitally  than  I  had 
thought  possible,  except  under  general  anaesthesia." — Kreiger, 
Tex.  C.-Rec.  Med. 

Care  must  be  taken  to  see  that  it  is  in  normal  condition,  that 
of  a  colorless  liquid,  for  by  exposure  to  the  light  bromine  is  set 


206  ARTIFICIAL    ANESTHESIA. 

free  and  colors  the  liquid.  Foreign  observers  are  most  pro- 
nounced in  its  favor,  and  more  practitioners  in  our  own  country 
should  put  investigations  on  record. 

Bromol  (tribromophenol)  is  not  new,  but  has  been  known 
as  the  product  of  the  action  of  bromine  in  excess  on  carbolic 
acid.  As  it  has  been  found  now  to  have  marked  antiseptic 
properties,  this  short  name  has  been  given  it,  both  for  conve- 
nience in  use  and  to  be  in  harmony  with  the  already  too  many 
new  compounds  being  pushed  forth,  most  of  which  have  names 
less  indicative  of  their  true  composition.  It  has  been  applied 
with  vaseline  to  open  wounds  with  success.  Its  internal  uses 
have  been  in  cases  of  typhoid  fever  and  cholera  infantum. 
Little  has  been  written  yet  on  its  therapeutic  uses. 

Butyl  Chloride. 

In  the  experiments  of  the  British  Committee  it  caused  the 
cardiac  pulsation  to  become  weaker,  and  finally  extinguished  ; 
while  methyl  chloride  only  effected  drowsiness.  Isohutyl  chloride 
was  not  noticed  as  regarding  any  cardiac  action. 

Iodide  of  Methyl.     (CH3I.) 

This  compound  was  discovered  by  Dumas  and  Peligot  in 
1835,  and  is  made  by  combining  phosphorus,  iodine  and 
methylic  alcohol.  A  safer  and  more  agreeable  preparation  of 
it  is  made,  according  to  Wanklyn,  by  mixing  iodide  of  potas- 
sium and  anhj'^drous  methylic  alcohol  in  a  retort,  in  equivalent 
proportions ;  dry  chlorine  gas  is  passed  into  the  mixture,  which 
is  then  distilled,  and  the  distillate  agitated  with  water  and 
rectified. 

Iodide  of  methyl  is  a  colorless  liquid  of  an  ethereal  odor. 
Specific  gravity,  2.199  at  32°  F. ;  it  boils  at  110°  F.,  and  burns 
with  difficulty,  giving  off  violet  vapors.  This  agent  was  pro- 
posed in  1 868  by  Dr.  B.  W.  Richardson  as  an  anaesthetic,  but 
was  found  by  him  and  by  Prof.  Simpson  as  unsafe.  It  has 
been  recommended  as  a  local  anaesthetic  in  cancerous  cases. 

Aniylene. 

The  vapor  of  this  liquid  was  introduced  by  the  late  Dr.  Snow 
as  a  substitute  for  the  vapor  of  chloroform.     It  produces  a  loss 


ALDEHYDE.  207 

of  sensibility  without  causing  complete  coma  or  stupor.  Its 
use  has  already  led  to  several  deaths,  and  is  not  even  as  safe  an 
agent  as  chloroform  vapor  for  surgical  purposes.  The  only 
appearance  met  with  in  one  fatal  case  was  an  emphysematous 
state  of  the  lungs,  or  an  excessive  dilatation  of  the  air-cells,  and 
in  the  other  a  distension  of  the  right  cavities  of  the  heart,  with 
dark  fluid  blood.  There  was  no  congestion  of  the  brain,  and 
no  smell  of  amylene  perceptible  in  the  body. 

Aldehyde.    (C2H4O.)    Etlialdehyde,  Acetic  or  Ethylic 

Aldehyde. 

Specific  gravity,  0.801  (32°  R);  boiling  point,  22"^  C.  (71.6° 
F.);  vapor  density,  1.532. 

Acetic  aldehyde  is  a  very  volatile  liquid,  produced  by  the 
oxidation  and  destructive  distillation  of  alcohol  and  other 
organic  compounds.  It  is  a  transparent,  colorless  liquid,  re- 
sembling the  ethers,  having  a  pungent,  suffocating  odor.  It  is 
very  inflammable,  and  burns  with  a  beautiful  blue  flame.  It  is 
mixed  with  water,  and  dissolves  in  alcohol  and  ether.  It  dis- 
solves sulphur  and  phosphorus,  also  iodine,  forming  a  brown 
solution,  and  becomes  chemically  changed  by  the  contact  or 
addition  of  an  oxidizing  agent  which  will  reduce  it  to  acetic 
acid.  Aldehyde  possesses  angesthetic  power ;  small  quantities 
of  the  vapor  retard  the  pulse,  large  quantities  accelerate  the 
pulse  and  respiratory  movements,  while  larger  doses  arrest 
them,  causing  irritation  of  the  glottis  and  constriction  of  the 
chest,  while  the  action  of  the  heart  is  disturbed,  with  a  ten- 
dency to  entire  arrest  of  respiration.  It  has  therefore  been 
classed  as  a  dangerous  anaesthetic.  Three  to  five  cubic  centi- 
metres (thirty-six  to  sixty  grains)  injected  in  watery  mixture 
into  the  veins  of  a  medium-sized  dog  produce  almost  immediate 
insensibility  and  arrest  of  respiration.  Death  is  preceded  by 
dilatation  of  the  pupils. 

Every  alcohol  can  become  an  aldehyde  by  oxidation.  The 
one  referred  to  differs  only  in  the  following  point :  First,  by  the 
prefix  par  multiplying  the  chemical  equivalent  by  four — 
CeHiaOs.     Again,  at  the  freezing-point  it  is,  like  oleic  acid,  a 


208  ARTIFICIAL    ANESTHESIA. 

solid.  In  its  physical  properties  it  is  precisely  the  same  as  the 
one  referred  to.  It  is  also,  according  to  our  experiments,  an 
anaesthetic — forty-five  minims,  being  inhaled  on  a  towel,  pro- 
duced a  choking,  disagreeable  sensation,  with  fulness  of  the 
head,  but  slight  anaesthetic  effect,  and  instead  of  accelerating 
the  pulse  it  reduces  it  from  96  to  80.  A  second  experiment 
was  made  with  sixty  minims,  when  there  was  considerable  irri- 
tation of  the  nose  and  throat  of  a  peppery  character  and  no 
full  anaesthesia,  but  the  pulse  rose  to  114.  The  respiration  was 
but  slightl}^  accelerated,  and  on  recovery,  which  was  rapid, 
there  was  no  severe  headache  and  no  sick  stomach  or  vomiting  ; 
there  was,  however,  considerable  irritation  of  the  conjunctiva 
and  slight  dilatation  of  the  pupil.  The  writer  has  tried  it  on 
himself  and  other  patients,  but  with  one  exception  it  has  been 
unsatisfactory.  In  a  case  of  neuralgia  of  the  fifth  pair,  cause 
exposure,  it  was  given  in  forty-five  minim  doses,  and  the  patient 
was  relieved  and  slept  all  night,  and  did  not  find  the  taste  so 
disagreeable  when  mixed  with  a  wine-glass  of  sugar  and  water. 
A  case  of  valvular  lesion  of  the  heart,  the  patient  not  being 
able  to  sleep  unless  under  the  influence  of  i  of  a  grain  of  mor- 
phia suppos.  and  xiu  of  atropia,  slept  only  two  hours  from  30 
minims  of  paraldehyde.  A  second  larger  dose,  45  minims,  had 
better  results  in  the  following  mixture  : 

Paraldehydi, "nixxx. 

Aqufe, adBiss. 

Syrupi  aurantii, 5ii. 

Spts.  chloroform!,       ......  "^Ixxx. 

M.  ft.  haustus.     Hora  somni  sumeod. 

"Chloral  Hydrate 

Is  an  anaesthetic  in  a  therapeutic  sense,  and  has,  like  chloro- 
form and  ethyl  bromide,  given  us  painful  instances  of  its  acting 
at  times  altogether  out  of  proportion  to  the  dose.  Fuller  {Lan- 
cet, March,  1871)  quotes  a  case  where  thirty  grains  caused 
death  in  a  young  lady.  Schwaighofer  [Irish,  Hospital  Gaz., 
1873)  reports  another,  of  a  drunkard,  in  which  a  drachm  pro- 
duced death ;  and  three  other    cases  (Reynolds,  Practitioner^ 


VALUE    OF    OXYGEN    GAS.  209 

March,  ISTO;  Watam,  Med.  and  Surgicnl  Reporter,  January, 
1871,  Fuller,  loc.  cit.),  in  which  forty-five,  eighty  and  thirty 
grains,  respectively,  caused  alarming  symptoms,  and,  from  the 
large  dose,  death  nearly  ensued.  Death  has  resulted  from  a  dose 
of  ten  grains  {American  Dispeiuatorri,  1880,  p.  396).  Other 
deaths  have  been  reported  {Mediccd  Times  and  Gaz.,  1871,  pp. 
1831,  672;  Norris,  Lancet,  1871,  i.  p.  226,  and  Browne,  ihid., 
p.  574) ;  and  in  some  of  these  cases  indisputable  evidences  of 
its  power  of  weakening  the  heart  were  present.  Did  chloral 
hj^drate  become  decomposed  in  the  system  into  formic  acid  and 
chloroform  (Personne,  Journ.  de  Pharm.  et  Chimie,  1870,  and 
Pellogio,  Schmidt's  Jahrhiicher,  bd.  cli.,  p.  89;  Liebreich, 
Wiener  Med.  Wochensch.,  August,  1860),  we  could  readily  ac- 
count for  its  acting  at  times  in  a  manner  wholly  disproportionate 
to  the  dose,  and  for  its  being  a  cardiac  depressant  :  but.  as  re- 
cent investigations  disprove  this  theory  (Hammertin,  Schmidt's 
Jahrhiicher,  bd.  cli.  ;  Rajursky,  Ibid.,  bd.  cli.  ;  Amory,  JV.  Y. 
Med.  Jour.,  1870  ;  Djurburg,  Schmidt's  Jahr.,  bd.  cli.  ;  Leuri- 
son.  Archil'.  Anat.  v.  Phys.,  1870),  we  must  look  elsewhere  for 
this  toxic  principle." 

Chloral  hydrate  has  been  advised  and  employed  in  combina- 
tion with,  or  given  before,  chloroform,  but  must  be  used  with 
care,  as  it  is  a  heart  depressant. 

On  the  Value  of  Oxygen  Gas  in  Prolonged  Opera- 
tions in  wliicli  Etlier  has  been  Administered 
as  the  Anaesthetic. 

This  gas  is  being  found  of  greater  value  and  more  extended 
application  every  day.  One  of  the  most  recent  has  been  its  use 
after  prolonged  operations  in  which  extreme  debility,  asphyxia 
with  cyanosis,  and  extreme  nausea  following  the  use  of  ether 
as  the  anaesthetic. 

It  is  therefore  with  pleasure  we  present  this  practical  paper 
of  Dr.  Hirsh,  written  at  our  request,  in  which  he  has  given,  in 
a  very  modest  way,  his  experience  of  its  value,  and  we  feel  sure, 
from  his  numerous  operations  with  it,  his  views  will  be  full}' 
appreciated  by  the  profession. 


210  ARTIFICIAL    ANESTHESIA. 

Oxygen  to  Antag-ouize  Etlier  Anaesthesia,  by  A.  B. 
Hirsh,  M.D.,  Philadelphia. 

"It  is  a  curious  fact  that,  of  the  countries  most  advanced  in 
surgical  science,  Grermany  should  find  fewest  advocates  among 
her  operators  for  that  safest  of  general  anaesthetics,  sulphuric 
ether.  Among  this  small  minority,  however,  is  Prof  Landon, 
the  eminent  gynaecologist  of  Berlin,  who,  in  the  course  of  his 
extensive  surgical  experience,  has  found  ample  cause  to  prefer 
ether  to  chloroform  or  any  mixture  or  substitute  for  these. 

"In  seeking  an  agent  which  would  remove  the  unpleasant 
effects  of  ether,  he  discovered  that,  when  the  inhalation  of  this 
article  was  followed  by  that  of  oxygen  gas,  the  object  was  at- 
tained, and  in  this  way  has  done  much  to  popularize  its  use  in 
his  own  and  other  countries  heretofore  prejudiced  against  ether 
narcosis. 

"Based  on  the  publications  of  Landon,  and  on  its  use  in  the 
major  operations  occurring  in  the  practice  of  his  friends  and 
self  in  Philadelphia,*  the  writer  is  prepared  to  urge  the  adop- 
tion of  the  Landon  method  for  all  cases  in  which  a  prolonged 
administration  of  ether  may  be  necessary. 

"  Its  very  simplicity  will  do  most  to  insure  universal  introduc- 
tion, as,  in  obtaining  the  required  articles  for  any  operation,  the 
surgeon  simply  orders  in  addition  a  steel  cylinder  containing 
from  fifty  to  one  hundred  gallons  of  oxygen  gas.  Now,  at  the 
end  of  the  operation,  or  if  at  any  stage  during  its  course  symp- 
toms of  cyanosis,  etc.,  demand  attention,  the  nozzle  of  the  dis- 
charging tube  on  the  apparatus  is  inserted  between  the  lips  or 
into  a  nostril,  and  the  oxj^gen  allowed  to  flow. 

"The  effects  are  so  marked  as  to  at  once  change  any  novice 
into  an  enthusiastic  adherent  of  the  method  ;  the  dusky,  livid 
hue  of  the  face  disappears  in  a  few  minutes,  while  the  pulse 
grows  fuller,  slower  and  more  rhythmical.  When  this  is  fully 
apparent,  the  oxygen  may  be  withdrawn.  Sometimes  twenty 
or  twenty-five  gallons  answers  the  purpose.     There  is  a  notably 

*  To  Prof.  Theophilus  Parvin,  of  Jeffersou  College,  Philadelphia, 
belongs  the  credit  of  its  introduction  in  this  country.  Vade  Medical 
and  Surgical  Eeporter,  August  17,  1896. 


ETHER  OR  CHLOROFORM WHICH  ?       211 

rapid  recovery  of  consciousness,  with  almost  entire  absence  of 
nausea,  headache  and  vomiting,  and  the  latter  symptoms  do  not 
recur.  The  avoidance  or  omission  of  such  causes  of  extreme 
prostration  after  anaesthesia  is  naturally  of  vital  importance  in 
the  case  of  previously  debilitated  patients  ;  furthermore,  its  im- 
portance is  emphasized  in  such  cases  because  it  permits  of  the 
taking  of  nourishment  within  a  few  hours  of  the  severest  kinds 
of  operations. 

■' The  after-course  of  an  operation  case  differs  so  markedly 
from  all  the  patient  has  been  led  to  await,  that  the  latter  usually 
expresses  his  sentiments  thereon  in  unmistakable  language." 

Ether  or  Chloroform — Which? 

A  valuable  contribution,  and  we  again  print  an  abstract  from 
our  third  edition  on  this  most  important  subject.* 

"Ether  is  the  weaker  anassthetic,  possessing  the  peculiar 
toxical  quality  in  less  degree  than  chloroform.  In  small  quan- 
tity it  is  decidedly  stimulating  to  the  cerebrum  and  to  the  vital 
functions  over  which  the  medulla  presides ;  and  in  this  action 
it  is  more  uniform  than  chloroform.  Indeed,  the  vital  reflexes 
are  so  uniformly  stimulated  by  ether,  that  the  danger  of  its 
primary  effects  in  healthy  subjects  is  as  small  as  possible  under 
general  anaesthesia.  In  those  who  take  ether  well,  the  stimu- 
lating effect  on  the  heart's  action  and  respiration  may  be  ob- 
served throughout  the  anaesthesia.  Ordinarily,  even  anassthetic 
doses  of  ether  do  not  depress  these  functions,  but  leave  them  to 
themselves,  uninfluenced  by  the  general  anaesthetic  action. 
Under  etherization  the  heart's  action  and  respiration  are  cer- 
tainly less  liable  to  the  irregularities,  which  are  not  nnfre- 
quently  observed  in  chloroform  anaesthesia.  In  the  latter 
stages  of  etherization,  however,  the  vital  reflexes  may  be  de- 
pressed, and  powerfully,  but  gradually,  so  as  to  give  warning 
of  the  approach  of  danger.  Ether  danger  usually  approaches 
by  way  of  the  lungs,  and  usually  forewarns  by  the  labored,  ster- 
torous, irregular  breathing  and  cyanosis,  so  as  to  allow  the  use 

*  Dr.  A.  B.  Miles,  New  Orleans  Medical  and  Surgical  Journal  (June 

27,  1887). 


212  ARTIFICIAL    ANAESTHESIA. 

of  means  to  avert.  Ether  danger,  however,  may  approach  by 
the  heart.  In  ten  of  forty  well-authenticated  ether  deaths  the 
heart  failed  first.  These  deaths  resemble  chloroform  deaths, 
but  comparatively  occur  much  less  frequently.  So  the  compar- 
ative safety  of  ether,  and  its  timely  admonition  of  danger,  are 
its  chief  advantages.  They  are  certainly  points  of  great  practi- 
cal value  in  its  favor. 

"Against  the  merits  of  ether  stand  in  stronger  relief  to-day 
than  ever  before  its  disadvantages  and  its  dangers.  The  advo- 
cates of  ether,  who  use  it  excessively,  especially  those  who  yet 
believe  in  its  absolute  safety,  are  doing  much  to-day  to  demon- 
strate its  dangers.  Its  inflammability  in  the  presence  of  artifi- 
cial light,  and  the  actual  cauteries,  is  one  objection.  The  dan- 
ger of  igniting  is  modified  by  several  conditions  :  the  proximity 
of  the  light,  its  position,  and  whether  exposed  or  not,  the  satu- 
ration of  the  surrounding  air  and  the  direction  of  the  air  cur- 
rents. Ether  may  ignite  at  long  distances  (fifteen  feet,  it  is 
said),  if  the  currents  set  in  the  direction  of  an  exposed  light. 
But  the  dangers  of  inflammability  may  be  modified  as  above  in- 
dicated, and  much  diminished.  The  exceedingly  disagreeable 
odor,  and  the  irritating  property  of  ether  when  brought  in  con- 
tact with  mucous  surfaces,  are  serious  disadvantages.  It  was 
this  irritating  property  which  refuted  the  claims  of  rectal 
etherization  as  a  warrantable  procedure  in  surgery,  but  not 
until  it  had  brought  sorrow  on  its  advocates,  and  a  worse  fate 
on  some  of  its  victims — diarrhoea,  dysentery,  haemorrhage,  col- 
lapse, death.  The  irritation  of  the  respiratory  mucous  mem- 
brane usually  causes  coughing,  strangling,  and  violent  resist- 
ance. It  may  cause  catarrhal  bronchitis  and  pneumonia.  It 
may  very  seriously  aggravate  a  pre-existing  bronchial  or  paren- 
chymatous inflammation. 

"The  excessive  secretion  which  ether  causes  to  flow  into  the 
breathing  passages  is  also  a  disadvantage  not  to  be  lightly  re- 
garded. This  may  endanger  life  by  sufi"ocation,  especially  in 
cases  of  pulmonary  disease,  already  attended  with  free  secretion, 
as  in  the  catarrhal  affections  of  children  and  old  people.  It  not 
unfrequently  prolongs  the  asphyxia  caused  by  the  usual  method 
of  administering  ether. 


ETHER  OR  CHLOROFORM WHICH  ?       213 

"  Patients  are  usually  asphyxiated  while  being  anaesthetized 
with  ether.  True,  the  asphyxia  favors  the  anaesthetic  effect  of 
ether,  and  therefore  obviates  the  necessity  of  too  greatly  satu- 
rating the  blood.  But  the  asphyxia  complicates  and  increases 
the  danger  of  anaesthesia.  The  dangers  of  such  a  state  are  be- 
yond question.  They  are  not  so  immediate  as  those  of  chloro- 
form, and,  therefore,  have  been  less  apparent  and  less  appre- 
ciated. 

"Asphyxia,  as  well  as  etherization,  maybe  carried  too  far, 
and  at  times  result  disastrously.  The  respiratory  nervous  ap- 
paratus is  exhausted,  and  the  heart  fails  secondarily.  The 
tone  of  its  own  texture  is  destroyed  by  the  supply  of  venous 
blood  and  by  impediment  to  the  pulmonary  circulation,  its  right 
ventricle  becomes  overdistended  and  powerless.  So  etheriza- 
tion, as  much  from  asphyxia,  due  to  the  manner  of  adminis- 
tration, as  from  its  ansesthetic  effect,  may  depress  the  heart's 
action  as  well  as  respiration.  But  the  sequelae  of  etherization 
are  matters  of  more  serious  importance,  to  wbich  attention  is 
specially  directed. 

"Aside  from  the  danger  of  inflammatory  diseases,  caused  by 
the  irritating  ether  vapor,  is  the  liability  to  pneumonia,  as  the 
result  of  obstructed  pulmonary  circulation. 

"Again,  the  asphyxia  which  goes  along  with  etherization  may 
increase  the  patient's  depression,  and  retard  reaction.  .  The 
deleterious  blood  changes  in  a  patient  who  has  undergone  pro- 
longed etherization,  cannot  be  well  suited  to  the  healing  of  im- 
portant wounds.  In  the  suffocating  plan  of  administering 
ether  the  blood  suffers  not  alone  of  the  interruption  to  the 
interchange  of  gases,  but  as  much  of  the  rebreathing  of  excre- 
mentitious  albuminoid  products,  which  physiologists  tell  us  are 
so  harmful. 

"The  danger  of  nephritis,  by  the  action  of  blood  saturated 
with  ether,  first  pointed  out  by  Dr.  Emmet,  of  New  York,  has 
been  authentically  confirmed  by  many  observers.  Healthy  or- 
gans may  be  acutely  inflamed,  and  those  previously  diseased 
may  be  greatly  aggravated,  by  the  passage  of  such  an  irritant 
over  their  secretory  surfaces.  The  danger  to  the  kidnej^s  led 
to  the  general  adoption  of  the  method  by  forced  etherization, 


214  ARTIFICIAL    ANAESTHESIA. 

by  which  the  asphyxia  lessens  the  quantity  of  the  ether  re- 
quired. 

''Ether,  more  frequently  than  chloroform,  causes  nausea  and 
vomiting.  This  is  an  important  consideration  in  the  selection  of 
an  ansesthetic  to  be  administered  in  cases  in  which  persistent 
retching  may  interfere  with  the  healing  of  important  wounds. 

"While  the  immediate  dangers  of  ether  are  comparatively 
slight,  those  which  occur  subsequently,  to  which  we  have  just 
alluded,  are  matters  of  very  serious  consequence.  These  dan- 
gers weigh  heavily  against  the  merits  of  this  anaesthetic. 

"  Now,  let  us  pass  in  running  review  the  advantages  and  dan- 
gers of  chloroform. 

"Its  non-inflammability  in  the  presence  of  artificial  light,  or 
the  actual  cauteries,  is  an  advantage  which  increases  greatly  the 
range  of  its  usefulness.  It  is  certainly  the  more  agreeable  to 
patients,  less  irritating  to  the  sensory  nerves  of  the  respiratory 
passages  and  the  more  enduring  in  its  ansesthetic  effect.  It 
causes  comparatively  little  increase  of  mucous  secretion.  It  is 
easier  of  administration,  and  the  mode  of  administration  does 
not  entail  anj^  other  effect  than  that  of  a  pure  and  simple  anaes- 
thetic. Chloroform  is  the  more  energetic  agent,  possessing  the 
inherent  toxical  quality  in  higher  degree  than  ether.  This 
quality,  however,  does  not  differ  in  character  from  that  which 
ether  possesses. 

"The  primary  effect  of  chloroform,  as  of  ether,  is  stimulating 
to  the  cerebrum  and  the  vital  functions ;  but  the  excitement  is 
less  intense  and  of  shorter  duration  than  in  etherization.  Being 
the  more  energetic  agent,  it  requires  less  saturation  of  the  sys- 
tem for  the  exercise  of  its  anaesthetic  power.  This  is  an  im- 
portant consideration.  The  practical  advantages  of  chloroform 
in  surgery  are  very  striking.  These  and  its  comparative  free- 
dom from  disastrous  sequelae  take  away  much  of  the  terror  of 
its  immediate  danger. 

"The  dangers  of  chloroform  are  soon  told.  They  are  imme- 
diate. If  patients  do  not  die  during  the  administration  they 
are  comparatively  safe.  Nearly  fifty  per  cent,  of  deaths  by 
chloroform  occur  at  the  outset  of  the  administration.  The  chief 
danger  of  chloroform  is   paralysis   of  the   nervous   apparatus 


ETHER    OR    CHLOROFORM WHICH  ?  215 

governing  circulation  and  respiration,  mentioned  in  the  order  of 
frequency.  The  centres  are  taken  by  surprise  by  the  direct  and 
energetic  action  of  chloroform,  and  overwhehned  quickly.  This 
sudden  action  has  given  to  chloroform  the  name  of  being  treach- 
erous. It  teaches  unmistakably  the  necessity  of  gradually 
accustoming  the  centres  to  the  influence  of  ana3sthetics.  We 
dwell  on  this  point  with  special  emphasis. 

''A  large  proportion  of  deaths  by  chloroform  are  reported  as 
occurring  suddenly,  and  without  warning.  These  cases  are 
usually  reported  in  a  way  to  lay  all  the  blame  on  chloroform. 
While  we  do  not  doubt  the  extreme  susceptibility  of  some  pa- 
tients, which  makes  them  liable  to  such  fatal  accidents,  we  are 
constrained  to  believe  that  in  more  instances  than  recorded  there 
are  timely  admonitions  of  danger.  These  admonitions  are  irreg- 
ularities of  the  heart's  action  and  respiration.  Experiments 
on  animals  have  shown  how,  under  chloroform  anaesthesia,  the 
heart  is  liable  to  sudden  irregularities.  Clinical  experience  con- 
firms the  observation.  Irregularity  of  the  heart's  action,  as 
regards  the  strength  of  its  beats,  is  especially  ominous.  The 
hesitating,  irregular  respiration  of  chloroform  anaesthesia  is  but 
little  less  valuable  as  a  warning  of  danger,  and  certainly  de- 
mands more  attention  than  usually  given.  The  statistics, 
before  mentioned,  show  that  in  one-fourth  of  forty  cases  of 
chloroform  death,  respiration  failed  before  the  heart's  action. 
Patients  who  breathe  irregularly  should  be  anaesthetized  with 
the  utmost  caution.  These  irregularities  of  the  heart  s  action 
and  respiration  indicate  a  condition  of  the  centres  which  bears 
anaesthetics  badly.  This  condition  is  more  frequently  observed 
in  the  anaemic  and  weakly,  and  those  under  the  influence  of 
depressing  emotions. 

"The  dangers  of  ether  and  of  chloroform  are  modified  by 
methods  of  administration.  Indeed,  we  feel  safe  in  venturing 
the  assertion  that  the  dangers  of  anaesthesia  lie  not  more  in  the 
inherent  property  of  the  agent  employed  than  in  the  manner  of 
its  administration. 

*' The  risks  are  very  much  greater  in  the  unskilful  adminis- 
tration of  chloroform  than  in  reckless  etherization.  In  view  of 
the  danger  of  its  primary  effect,  we  insist  here  on  the  advisa- 


216  ARTIFICIAL    ANESTHESIA. 

bility  of  preparing  the  way  for  chloroform.  Agents  should  be 
given  in  advance  to  stimulate  the  vital  reflexes  and  prepare  the 
nerve  centres  for  the  coming  anaesthetic  effect. 

"The  old-fashioned  whiskey  toddy,  taken  just  before  the  an- 
aesthetic, still  has  its  votaries.  The  use  of  alcohol  in  this  way 
is  objectionable.  We  cannot  rely  on  absorption  from  the 
stomach  at  the  very  time  its  stimulating  action  is  most  desir- 
able. If  given  immediately  before  the  anaesthetic,  it  is  not  ab- 
sorbed in  time  to  sustain  the  centres  as  they  undergo  primary 
anaesthesia.  If  given  in  time  for  absorption,  the  alcohol  antag- 
onizes the  action  of  the  anaesthetic.  Alcoholic  patients  are 
difficult  to  anaesthetize,  and  while  under  anaesthesia  they  often 
show  alarming  symptoms."^ 

"Again,  alcohol  is  uncertain  in  the  physiological  action  for 
which  it  is  given.  In  many  subjects,  by  abuse,  perhaps  it  may 
have  long  since  lost  its  medicinal  virtue,  while  in  others  its 
effect  may  be  variable  because  of  nervous  susceptibility.  Alco- 
hol taken  into  the  stomach  before  anaesthesia  has  the  efl"ect  of 
exciting  many  patients  after  a  surgical  operation,  at  the  time 
when  it  is  most  desirable  that  they  should  be  calm.  This  ex- 
citement may  increase  the  liability  to  inflammation.  The  maxi- 
mum good,  with  the  least  harm,  follows  the  use  of  alcohol 
when  administered  hypodermatically  or  by  inhalation  at  the 
outset  of  anaesthesia.  The  first  whiffs  of  chloroform  may  well 
be  mixed  with  the  vapor  of  alcohol. 

"A  few  breaths  of  the  vapor  of  ammonia  in  advance  of  chlo- 
roform act  like  alcohol,  but  more  potently,  and  without  its  dis- 
agreeable eff'ects. 

"  The  method  of  mixed  anaesthesia  by  the  hypodermatic  ad- 
ministration of  the  sulphate  of  morphia  alone,  or  in  combination 
with  a  respiratory  stimulant,  as  the  sulphate  of  atropia,  is  as 
sound  in  physiological  principle  as  useful  in  practice.!  The 
doses  of  the  sulphate  of  morphia  in  adults  should  not  exceed 
one-twelfth  to  one-sixth  of  a  grain  ;  of  the  sulphate  of  atropia, 
one  two-hundredth  to  one  one-hundred  and  fiftieth  of  a  grain, 

*■  See  article  on  "Alcohol  in  Operations." 

"f"  But  not  always  in  practice,  on  account  of  idiosyncrasy  of  patient. 


ETHER  OR  CHLOROFORM WHICH  ?       217 

The  atropine  acts  particularly  well  in  states  of  bronchial  catarrh, 
in  pulmonary  diseases,  and  in  all  cases  indicating  the  action  of 
a  respiratory  stimulant.  The  hypodermatic  use  of  morphine, 
in  the  doses  recommended,  secures  the  primary  stimulant  effect 
promptly  when  desired,  aids  the  anaesthetic  in  its  action,  and 
subsequently  promotes  the  relief  necessary  after  surgical  pro- 
cedures. 

'^A  safe  way  of  preparing  the  centres  fur  cliloroform,  and  one 
which  we  strongly  recommend,  is  by  stimulating  them  prima- 
rily with  the  inhalation  of  ether.  The  centres  more  easily  ad- 
just themselves  to  the  action  of  ether.  Statistics  show  that  the 
danger  of  the  first  effect  of  ether  is  almost  infinitesimal.  Thus 
the  anaesthesia  is  begun  with  the  agent  safer  at  the  beginning, 
and  continued  with  the  agent  less  harmful  in  its  subsequent 
effects. 

"There  are  causes  of  danger  in  the  administration  of  chloro- 
form which  occur  so  commonly  as  to  warrant  special  mention 
here.  Chief  among  these  common  causes  of  fatal  accidents  is 
overdosage — an  excessive  amount  in  a  given  time.  Patients 
being  anaesthetized  with  chloroform  should  never  experience 
the  sense  of  suffocation  of  which  we  too  frequently  hear  them 
complain.  Coughing  early  in  the  ansesthesia  is  usually  an  evi- 
dence of  overaction.  Chloroform  anaesthesia  should  be  begun 
with  minimum  doses — a  few  drops  only — and  continued  to  the 
degree  desired  in  quantities  gradually  increasing.  To  over- 
dosage, more  than  to  idiosyncrasy  of  patients,  should  be  at- 
tributed most  of  the  accidents  by  chloroform.  Witness  the 
manner  in  which  so  many  physicians  give  chloroform  by  satu- 
rating the  inhaler  at  the  outset  and  forcing  the  anaesthesia,  and 
there  will  be  less  difficulty  in  explaining  many  of  those  deaths 
that  occur  with  such  electric  suddenness. 

"Haste  in  the  administration  of  chloroform  deserves  most 
emphatic  condemnation.  The  anaesthesia  should  be  produced 
gradually  and  maintained  uniformly.  We  believe  it  unsafe  to 
advise  patients  at  the  beginning  to  '  take  long  breaths,'  with  the 
view  of  quickly  inflating  the  lungs  with  saturated  air  in  order 
to  produce  a  rapid  effect. 

"In   the   calm   which   follows  the   preliminary  excitement, 

15 


218  ARTIFICIAL    ANESTHESIA. 

chloroform  acts  with  increased  energy.  The  centres  are  at  this 
moment  in  a  state  of  exhaustion,  and  not  prepared  to  have  the 
anaesthesia  forced.  The  depression  whicli  follows  the  primary 
excitement  is  a  period  in  which  much  harm  may  be  done  by 
overdoses  of  chloroform. 

"Instead  of  forcing  chloroform  anaesthesia  at  any  time  during 
its  administration,  it  is  better  now  and  then  to  give  the  patient 
a  rest  spell,  in  order  to  refresh  the  residual  air  of  the  lungs. 
Some  of  the  singularly  sudden  deaths,  of  which  we  read,  may 
be  accounted  for  by  the  cumulative  effect  on  the  centres,  caused 
by  the  sudden  absorption  of  vapor  whicli  saturates  the  re- 
sidual air. 

"Recent  statistics  are  not  wanting  by  which  we  can  accu- 
rately estimate  the  relative  death-rate  caused  by  ether  and 
chloroform. ' ' 

On  Blood -Alterations  by  Ether. 

In  the  researches  made  with  nitrous  oxide,  when  given  simply 
to  the  point  of  producing  anaesthesia  for  all  surgical  operations, 
there  occur  no  true  poisonous  results.  The  repeated  attempts 
to  produce  such  a  spectrum  peculiar  to  this  agent  have  been,  as 
yet,  unsuccessful,  the  only  bands  discernible  being  the  broad  one 
between  Fraunhofer's  D  and  E  lines,  which  represents  the  spec- 
trum of  reduced  haemoglobin.     (See  experiments  of  author.) 

In  recent  years  a  number  of  careful  observations  have  been 
made  by  reliable  observers  to  determine  the  amount  of  haemo- 
globin* lost  during  the  anaesthetic  state  induced  by  both  chloro- 

*  "  Hsemoglobin  (hsem-o-glo-bin),  hsema,  blood,  and  globus,  a  round 
body.  Hsemaloglobin,  hsemocrystallin ;  a  doubly-refractive,  pleo* 
chromatic  colloid  or  crystalline  matter  existing  in  the  corpuscles  of 
the  blood,  and  to  which  their  red  color  is  due. 

"  In  man,  the  amount  is  13.77  per  cent. ;  in  woman,  12.50  per  cent, ; 
reduced  by  pregnancy  to  from  9  to  12  per  cent.  It  is  an  oxygen  car- 
rier or  respiratory  pigment.  The  crystals  of  hgemoglobiu  have  a  dark- 
red  appearance,  with  a  strong  purple  or  bluish  tint ;  they  are  very 
soluble  in  water." — Gould  Diet. 

The  Blood-Alterations  of  Ether  Anaesthesia,  by  John  Chalmers  Da 
Costa,  M.D.     Pamphlet,  pp.  28.     From  the  Medical  News. 


ON    BLOOD-ALTERATIONS    BY    ETHER.  219 

form  and  ether.  The  following  results  were  obtained  by  Dr. 
John  Chalmers  Da  Costa,  of  Philadelphia.  After  some  pre- 
liminary observations  on  artificially  induced  unconsciousness, 
which  is  known  as  anaesthesia  produced  by  sudden  diminution 
of  the  amount  of  blood  in  the  brain,  such  as  is  seen  after  severe 
haemorrhage,  ligation  of  the  carotid  artery,  forcible  and  rapid 
respiration,  probably  as  a  result  of  anaemia  of  the  brain,  he 
then  points  out  that  anaesthesia  may  be  produced  by  alterations 
in  the  composition  of  the  blood,  and  the  carrying  in  this  fluid 
of  certain  extraneous  materials  to  the  nerve  centres,  as  exhibited 
in  carbonic  acid  and  narcosis,  in  which  condition  the  internal 
respiration  is  diminished,  and  the  activity  of  the  cerebral  cells 
is  depressed  or  destroyed.  Another  example  of  angesthesia  by 
alteration  in  the  composition  of  the  blood,  is  seen  in  the  inhala- 
tion of  ether  and  chloroform, 

"  For  almost  fifty  3'ears  e^Ae?' has  been  under  scientific  inves- 
tigation, and  it  is  generally  agreed  that  it  acts  on  the  nervous 
system  as  does  alcohol,  only  far  more  rapidly.  When  given  by 
inhalation,  there  are  four  stages  of  anaesthesia  : 

"1.  The  stage  of  stimulation,  characterized  by  excitement 
and  a  pleasing  intoxication. 

"2.  The  anodyne  stage,  characterized  by  impaired  sensation, 
retained  reflexes,  delirium,  which  is  most  marked  in  robust 
individuals,  tetanic  contraction  of  the  muscles,  turgescence  of 
the  face,  etc. 

"3.  The  anaesthetic  stage,  characterized  by  the  abolition  of 
the  ordinary  reflexes  and  of  all  conscious  excito-motor  sensi- 
bility. 

"4.  The  paralytic  stage,  characterized  by  diminution  of  un- 
conscious excito-motor  sensibilities,  and,  finally,  by  death  from 
paralysis  of  the  respiratory  centre. 

"  The  condition  of  anaesthesia  is  thought  by  most  observers 
to  be  due  to  the  passage  of  ether  into  the  blood,  and  the  subse- 
quent direct  action  of  this  drug  upon  the  nerve  elements.  Pre- 
vost  has  sought  to  prove  this  bj^-  a  well-known  experiment.  He 
produced  unconsciousness  in  a  frog  by  the  direct  application  of 
the  drug  to  the  cerebrum,  after  first  tying  tlie  aorta  to  prevent 
the  washing  away  of  the  agent  by  the  force  of  the  circulation. 


220  ARTIFICIAL    ANAESTHESIA. 

The  defect  in  his  experiment  is  the  fact  that  the  ligation  of  the 
aorta,  by  depriving  the  brain  of  blood,  might  be  responsible  for 
the  unconsciousness. 

"It  seems  highly  probable,  from  a  series  of  observations, 
that  the  cause  of  the  anaesthetic  state  is  not  merely  the  direct 
action  of  ether  upon  the  nerve  elements,  but  involves  likewise 
an  alteration  in  the  composition  of  the  blood.  It  is  a  well- 
known  fact  that  slow,  chronic,  advancing  nutritive  failure  of  the 
brain  is  first  manifest  in  the  decay  of  the  higher  and  most  un- 
stable faculties,  which  are  the  last  products  of  evolutionary  ad- 
vance, and  that  the  last  faculties  to  suffer  are  those  that  are 
purely  automatic.  Consciousness  is  not  lost  early  in  these  con- 
ditions because  cells  producing  cerebral  activities,  of  which  con- 
sciousness manifests  the  sum,  have  time  in  chronic  failures  to 
adjust  themselves  to  their  altering  environment. 

' '  That  the  diminution  of  the  amount  of  oxyhaemoglobin  does 
tend  to  produce  unconsciousness  is  shown  by  the  drowsiness, 
the  heaviness,  and  the  tendency  to  syncope  shown  by  sufferers 
from  chlorosis,  by  the  almost  comatose  condition  of  the  victims 
of  Winckel's  disease,  and  by  the  abolition  of  sensibility  of  rab- 
bits and  guinea- pigs  in  which  this  disease  has  been  artificially 
produced,  and  yet  in  these  conditions  the  alteration  of  blood 
composition  is  rather  gradual  than  sudden. 

"The  following  observation  will  show  that  diminution  in 
haemoglobin  is  constant  after  the  inhalation  of  ether  ;  that  the 
diminution  is  rapid  and  marked,  is  accompanied  by  alteration 
in  the  shape  of  the  corpuscles,  but  by  no  marked  diminution  in 
their  number.  This  diminution  in  the  amount  of  haemoglobin 
is  so  pronounced  in  the  anaemic  as  to  give  conclusive  evidence 
of  the  reason  why  reaction  in  these  cases  is  often  so  difficult, 
and  the  effect  of  the  anaesthetic  so  persistent  and  prolonged. 

' '  The  exact  mode  in  which  the  haemoglobin  is  removed  from 
the  corpuscles  is  questionable.  Practically  we  know  that  if 
blood  outside  of  the  body  is  subjected  to  a  low  temperature, 
and  subsequently  warmed,  the  coloring  matter  of  the  corpuscles 
passes  into  the  blood  liquor.  Theoretically  we  may  assume  that 
the  rapid  evaporation  of  ether  in  the  air  cells  of  the  lungs  pro- 
duces great  cold,  and  that  the  blood  circulating  through  the 


ON    BLOOD-ALTERATIONS    BY    ETHER.  221 

rest  of  the  body  becomes  subsequently  warmed,  and  the  haemo- 
globin is  thus  removed. 

"  This  theory  finds  apparent  confirmation  in  the  rapid  lower- 
ing of  temperature  induced  by  anaesthetics,  a  lowering  that  be- 
gins with  the  anodyne  stage,  and  that  may  reach  the  extent  of 
four  or  five  degrees.  In  the  cases  in  which  I  have  made  studies 
of  temperature  the  average  fall  was  found  to  be  from  one  to 
three  degrees,  a  fall  separated  from  the  fall  of  shock  by  the  fact 
of  the  rapid  ascent  of  the  temperature  on  cessation  of  inhalation 
of  the  anaesthetic. 

"The  altered  shape  of  the  corpuscles  may  in  part  be  due  to 
the  removal  of  the  haemoglobin,  and  in  part  to  the  dissolving  out 
of  some  of  the  fat  which  they  contain.  What  becomes  of  the 
hgemoglobin  removed  from  the  corpuscles  is  a  question,  though 
the  occasional  occurrence  immediately  after  etherization  of  se- 
vere jaundice  would  seem  to  indicate  that  in  some  cases  at  least 
this  pigment  goes  to  the  liver  and  is  there  broken  up.  In  con- 
firmation of  the  foregoing  views  I  submit  twenty-nine  cases  in 
which  blood  examinations  have  been  most  carefully  made  before, 
during  and  after  etherization. 

"  The  counts  were  made  by  means  of  a  Thoma-Zeiss  haemo- 
cytometer ;  the  haemoglobin  was  estimated  by  means  of  Gowers' 
and  Fleischl's  haemoglobinometers ;  drawings  have  been  made 
from  the  undiluted  blood,  and  of  necessity  are  diagrammatic  ; 
all  forms  of  the  red  corpuscles  being  represented  by  red  ;  leuko- 
cytes, by  pale  blue ;  lymphocytes,  by  dfirk  blue  ;  and  blood 
plates  by  green.  In  making  the  blood  counts,  the  solutions 
used  for  dilution  were  the  three  per  cent,  salt  solution  and  the 
Daland's  potassium -bichromate  solution. 

"The  estimation  in  these  cases  was  made  just  before  etheri- 
zation, during  etherization,  and  after  recovery  from  the  anaes- 
thetic state.  Case  XIII.  was  subjected  to  an  estimation  three 
days  before  the  operation,  two  days  before  the  operation,  one 
'day  before,  and  just  before  operation,  during  slight  anaesthesia, 
during  profound  anaesthesia,  in  the  beginning  of  recovery,  and 
the  day  after  the  operation.  Case  XXIII.  died  of  shock  after 
the  operation  of  gastroenterostomy,  and  sufficient  recovery  did 
not  follow  operation  to  permit  of  estimation  being  made.     The 


222  ARTIFICIAL    ANESTHESIA. 

other  cases  are  free  from  complication  of  shock  or  severe  haem- 
orrhage, and  afford  pure  instances  of  ether  action.  Case  XITI. 
was  one  of  examination  for  stricture  of  the  rectum,  a  rectal 
bougie  was  passed,  and  there  was  absolutely  no  haemorrhage. 
Case  XXI.  was  one  of  attempted  reduction  of  an  old  inguinal 
hernia,  and  was  uncomplicated  by  bleeding.  Case  XXVII. 
was  one  of  breaking  up  of  an  ankylosis  of  the  finger,  and  was 
also  unaccompanied  by  haemorrhage.  Case  III.  does  not  show 
a  reduction  of  haemoglobin.  This  apparent  discrepancy  arises 
from  the  estimation  having  been  made  without  artificial  light, 
and  report  of  this  case  is  made  only  to  maintain  scientific  con- 
sistency ;  it  can  be  unhesitatingly  rejected  from  the  case  group. 
Case  XIX.  was  an  alcoholic,  never  completely  under  the  influ- 
ence of  the  ether,  and  examination  showed  no  apparent  fall 
of  haemoglobin,  although  after  etherization  the  haemoglobin 
was  found  diminished.  This  was  due  to  too  early  observa- 
tion, the  blood  being  taken  during  a  period  of  excitement  in 
which  there  were  violent  struggling  and  tumultuous  respiratory 
efforts." 

In  twenty-seven  cases  the  fall  of  haemoglobin  is  marked  and 
unmistakable.  Each  case  is  accompanied  by  a  report  of  the 
physical  condition  of  the  individual  and  a  urinary  examination, 
with  a  description  of  the  blood  as  examined  by  a  Leitz  y^  oil 
immersion,  the  slide  being  undiluted  blood. 

"The  haemoglobin,  before  etherization,  ranged  as  high  as 
70  ;  blood  examination  during  etherization  was  reduced  from 
five  to  ten  per  cent.  This  was  an  exceptionable  case  in  which 
the  haemoglobin  was  increased. 

"Case  XXVIII.— Patient,  W.  D.,  aged  fifty-five  years. 
Physical  examination  negative.  Urine  examination,  negative. 
Blood  examination  before  etherization :  Haemoglobin,  sixty-two 
per  cent,  of  normal.  Red  corpuscles  per  cubic  millimeter,  total, 
4,800,000.  Red  corpuscles  per  cubic  millimeter,  normal,  5,500,- 
000.  White  corpuscles  per  cubic  millimeter,  10,000.  Proportion 
of  white  to  total  red,  1 :  480.  Proportion  of  white  to  normal  red, 
1  :  450.     Appearance  of  corpuscles  practically  normal. 

"  Blood  examination  during  etherization:  Haemoglobin,  fifty- 
five  per  cent,  of  normal.     Red  corpuscles  per  cubic  millimeter, 


ON    BLOOD-ALTERATIONS    BY    ETHER.  223 

total,  5,000,000.  Red  corpuscles  per  cubic  millimeter,  normal, 
3,000,000.  White  corpuscles  per  cubic  millimeter,  12,000. 
Proportion  of  white  to  total  red,  1  :  417.  Proportion  of  white 
to  normal  red,  1 :  250.  The  slides  showed  normal  red,  irregular 
red,  and  granular  leukocytes. 

"Blood  examination  after  etherization.  Haemoglobin,  sixty 
per  cent,  of  normal.  Pved  corpuscles  per  cubic  millimeter,  total, 
4,480,000.  Red  corpuscles  per  cubic  millimeter,  normal,  2,000,- 
000.  White  corpuscles  per  cubic  millimeter,  12,000.  Propor- 
tion of  white  to  total  red,  1 :  370.  Proportion  of  white  to  nor- 
mal red,  1  :  166.  The  slides  showed  normal  red,  diseased  red, 
and  granular  leukocytes." 

An  accurate  detail  of  twenty-eight  cases  is  given  and  the  fol- 
lowing conclusions  are  reached  : 

"  1 .  Etherization  produces  a  marked  diminution  in  the  haemo- 
globin of  the  blood. 

"2.  The  red  corpuscles  and  the  haemoglobin  are  especially 
affected  in  blood  previously  diseased,  in  such  conditions,  for 
instance,  as  anaemia." 

"3.  Irregular  reports  are  due  to  faulty  observations,  to  the 
presence  of  altered  hemoglobin  in  the  blood,  to  the  faulty  aber- 
ration as  to  color  of  Fleischl  instrument  or  to  taking  the  blood 
before  anaesthesia  is  complete. 

■ '  4.  The  white  corpuscles  show  irregular  changes  which  are 
not  characteristic,  and  exhibit  variations  not  more  pronounced 
than  would  be  found  in  the  same  number  of  samples  of  normal 
blood  on  different  examinations. 

"5.  Age  does  not  apparently  influence  the  results. 
"  6.  Ether-pneumonia  may  possibly  be  due,  in  some  instances 
at  least,  to  the  action  of  intense  cold  upon  the  lungs,  produced 
by  the  action  of  ether-vapor. 

"  7.  (Edema  of  the  lungs  may  arise  from  contraction  of  the 
pulmonary  capillaries,  thus  producing  a  loss  of  vis  a  tergo  and 
damming  up  of  blood  in  the  veins.  Furthermore,  the  same 
condition  may  produce  sudden  paralysis  of  the  heart. 

"8.  The  often-quoted  observation  as  to  the  effect  upon  the 
haemoglobin  of  shock  and  haemorrhage  requires  enlarged  repe- 
tition upon  human  beings  before  the  statement  can  be  unre- 


224  ARTIFICIAL    ANESTHESIA. 

servedl}^  accepted,  that  haemorrhage  causes  a  great  fall  in  the 
amount  of  hajmoglobin,  but  that  shock  does  not  aifect  it. 

"  9.  The  chilling  of  the  blood-stream  may  be  responsible  for 
the  nephritis  that  occasionally  follows  etherization. 

"  10.  Prolonged  anajsthesia  profoundly  deteriorates  the  blood 
and  strongly  militates  against  recovery ;  hence  the  rapidity  of 
operation  is  most  desirable." 

These  observations  and  experiments  will  require  confirmation. 

The  Influence  of  Angestlietics  on  the  Kidneys,  More 
Especially  Ether  and  Chloroform. 

Under  alcohol  we  have  shown  the  effects  of  alcohol  on  the 
kidneys  and  liver,  by  the  late  coroner's  physician  of  Philadel- 
phia, Dr.  H.  F.  Formad.  We  now  extract  from  a  late  pam- 
phlet of  Dr.  H.  C.  Wood's  some  valuable  facts  by  him,  and 
experiments  of  his  son,  Dr.  George  B.  Wood,  on  this  same 
subject.  We  are  pleased  that  so  high  an  authority  as  Dr.  Wood 
so  fully  agrees  with  the  importance  of  the  careful  examination 
of  the  kidneys,  and  the  importance  of  recording  the  habits  of 
the  patient  in  regard  to  the  constant  use  of  stimulants,  espe- 
cially alcohol. 

"Kidneys. — Writing  in  1890,  Dr.  Laurence  TurnbuU  said 
that  '  it  is  of  the  greatest  importance  that  attention  should  be 
given  to  the  condition  of  the  kidnej^s,  and  an  examination  made 
of  the  urine  when  an  anaesthetic  is  to  be  administered.  Deaths, 
unaccountable  otherwise,  are  due  to  this  cause.  In  diseases  of 
the  kidneys,  the  blood  being  loaded  with  urea,  anaesthetics 
almost  invariably  produce  convulsions,  coma  and  death.'  These 
words  of  Dr.  TurnbuU  reflect  a  widespread  professional  opinion. 
If,  then,  disease  of  the  kidneys  be  so  strong  a  contraindication 
to  the  use  of  anaesthetics,  it  is  necessary  to  examine  very  care- 
fully as  to  the  proper  choice  of  the  anaesthetics  when,  notwith- 
standing the  existence  of  renal  disease,  anaesthesia  must  be 
superinduced.  It  is  plain  that  two  distinct  dangers  underlie 
the  use  of  the  anaesthetic  in  renal  disease  ;  one  has  to  do  with 
the  influence  of  the  drug  upon  the  diseased  kidneys ;  the  other 
has  to  do  with  the  relations  between  the  secondary  conditions 


INFLUENCE    OF    ANESTHETICS    ON    THE    KIDNEYS.        225 

of  Briirlit's  disease  and  the  anaesthetic.  Marked  atheromatous 
arteries  contraindicate  nitrons  oxide  ;  a  degenerated  heart- 
muscle  contraindicates  chloroform  ;  and  it  may  very  well  be 
that  sometimes  the  choice  of  the  surgeon  should  light  upon  the 
anaesthetic  which  threatens  the  kidneys  most,  because  it  is  the 
least  dangerous  to  those  organs  which  have  become  secondarily 
diseased. 

"As  throwing  light  upon  sudden  death  during  anaesthesia  it 
is  worthy  of  note  that  in  Dr.  Greorge  B.  Wood's  experiments, 
referred  to  below,  several  times  in  dogs  who  were  suffering  from 
nephritis  artificially  produced  by  the  use  of  cantharides  or  pres- 
ent as  the  outcome  of  natural  disease,  sudden  fatal  arrest  of  res- 
piration occurred,  suggesting  that  there  may  be  in  uraemia  or 
ur^emic  conditions  a  special  inability  of  the  respiratory  centres 
to  resist  the  effects  of  narcotic  poisons,  and  that  amongst  the 
secondary  effects  of  Bright' s  disease  should  be  put  lack  of  re- 
sistive power  in  the  respiratory  centres. 

"  In  attempting  to  decide  as  to  the  choice  of  au  anaesthetic  for 
an  uraemic  patient  it  is  proper  first  to  study  the  relations  of  the 
ana3sthetic  to  the  kidneys  themselves.  So  far  as  my  reading 
goes.  Dr.  Thomas  A.  Emmet,  of  New  York,  was  the  first  to 
call  attention  to  the  possibility  of  the  production  of  fatal  sup- 
pression of  urine  in  persons  suffering  from  chronic  Bright's 
disease  by  the  use  of  ether.  In  his  first  experience  complete 
suppression,  and  death  in  three  days  from  uraemia,  occurred  in 
a  patient  suffering  from  chronic  cystitis  and  probably  renal  de- 
generation. Subsequently  to  this  Dr.  Emmet  is  said  to  have 
had  five  such  cases.  Without  attempting  to  go  over  the  whole 
literature  of  the  subject,  attention  may  be  called  to  the  cases 
reported  by  Professor  W.  F.  Norris  to  the  American  Ophthal- 
mological  Society  in  1S81,  especially  to  the  one  in  which  death 
in  convulsions  followed  ether  anaesthesia  in  a  child  suffering 
from  fatty  kidneys,  and  in  which  after  death  the  kidnej^s  were 
found  intensely  congested.  Various  cases  similar  to  these  have 
been  published  in  medical  literature,  and  it  does  not  suffice  to 
answer,  as  has  been  done,  that  ether  has  been  frequently  em- 
ployed in  Bright's  disease  without  bad  results. 

"  It  ought  to  be  possible  to  positively  determine  whether  or 


226  ARTIFICIAL    ANESTHESIA. 

not  ether  is  capable  of  affecting  the  secreting  structure  of  the 
normal  kidney.  In  the  British  Medical  Journal  Dr.  Lawson 
Tait  records  a  remarkable  case,  in  which,  the  ureters  being  ex- 
posed, it  was  found  that  the  continuous  administration  of  ether 
prevented  the  secretion  of  urine,  and  so  long  as  the  narcosis 
persisted  there  was  no  flow  of  urine.  This  observation  is  said 
to  have  been  repeatedly  confirmed  by  Tait  himself,  and  is  of 
great  importance  as  evidence  that  ether  does  affect  the  human 
kidney.  It  is  evident  that  experiments  upon  animals  should  be 
made,  in  which,  the  ureters  having  been  exposed  and  canulated, 
it  should  be  determined  whether  these  observations  of  Tait  are 
exceptional  or  not.  Albuminuria  after  ordinary  anaesthesia  is 
probably  rare,  but  it  certainly  does  occur  at  times.  Patein  found 
it  once  in  every  three  cases,  but  this  is  plainly  much  above  the 
average.  In  elaborate  studies  made  in  the  physiological  laboratory 
of  the  University  of  Pennsylvania  by  my  son,  Dr.  George  B. 
Wood,  it  was  found  in  dogs  that  during  ether  anaesthesia  the  kid-- 
neys  become  markedly  congested,  and  almost  invariably,  if  the 
anaesthesia  had  been  protracted  over  fifteen  minutes  and  the  dog 
then  killed,  it  was  possible  to  demonstrate  cloudy  swelling  of  the 
nuclei  and  contents  of  the  secreting  cells.  The  cells  of  the  con- 
voluted tubules  were  those  primarily  affected,  the  tufts  and  cor- 
responding tubules  only  showing  change  when  the  anaesthesia 
had  been  greatly  prolonged.  It  is  true  that  Fueter  failed  to 
detect  changes  in  the  kidneys  of  etherized  dogs,  but  this  nega- 
tive testimony  can  hardly  stand  against  the  positive  evidence  with 
specimens  which  were  studied  and  accepted  as  conclusive  by 
Dr.  G-uiteras,  professor  of  pathology  in  the  University  of  Penn- 
sylvania."* 

*  University  Medical  Magaziue,  vi.,  1894,  p.  802. 


BROMIDE    OF    ETHYL.  227 


CHAPTER    VI  I. 

Hydrobromic  Ether  or  the  Bromide  of  Ethyl — Chemical  Nature, 
Properties,  Decompositions,  etc. — As  an  Anaesthetic  in  Labor,  in 
Dental  Operations — Table  of  the  Purity  of  Various  Specimens  of 
Bromide  of  Ethyl. 

Hydrobroiiiic  Ether  or  Bromide  of  Ethyl.     (CjH.Br.) 

Properties.— Bromide  of  ethyl  (CaHjBr.),  or  ''hydrobro- 
mic ether,"  is  a  colorless  liquid,  with  an  agreeable  odor;  it  boils 
at  about  40.7°  C.  (105.8°  F.);  has  a  density  of  1.475  at  15°  C. 
(59°  F. ) ;  the  boiling  point  and  the  density,  are,  therefore,  inter- 
mediate between  those  of  chloroform  and  sulphuric  ether. 

The  Mode  of  Preparation. — Distil  a  mixture  of  4  parts  of 
bromide  of  potassium,  4  parts  acid  sulphuric  and  2  parts  alco- 
hol. This  is  the  formula  of  the  French  Codex  of  1884.  To 
cheapen  it  they  now  introduce  into  a  tubular  retort,  surrounded 
by  ice  water,  30  to  40  grammes  of  red  phosphorus,  and  200 
grammes  of  very  concentrated  alcohol,  in  which  was  dissolved 
200  grammes  of  bromine. 

We  thus  produce  hydrobromic  acid,  which  reacts  on  the 
alcohol  in  a  nascent  state,  the  whole  is  left  to  digest  for  some 
time,  then  distilled  and  is  precipitated  by  water,  the  condensed 
product  is  then  decanted  and  the  heavy  liquid  falling  to  the 
bottom  is  digested  on  chloride  of  calcium  to  dry  it. 

Bromide  of  Ethyl.     (CzH^Br.) 

Transparent  and  colorless  liquid,  heavier  than  water  (Serul- 
las) ;  specific  gravity  1.40  (Lbwig),  1.4733  at  0°  (Pierre) ;  vapor 
density  3.754  (R.  Marchand  J.  per  cm.  188);  very  volatile; 
boiling-point  40. 7°  C.  when  the  barometer  stands  at  757  mm. 
(Pierre) ;  has  a  strong  ethereal  odor  and  pungent  taste  (Serullas). 
According  to  Lowig,  its  taste  is  strongly  and  agreeably  sweetish, 
with  a  somewhat  burning  after-taste.  The  vapor,  when  inhaled, 
exerts  an  anaesthetic  action,  like  chloroform  (Robin,    Compt. 


228  ARTIFICIAL    ANAESTHESIA. 

Rend.  xxx.  669).     It  is  sparingly  soluble  in  water,  but  mixes  in 
all  proportions  with  alcohol  and  ether. 

Decompositions. — 1.  Yapor  of  hydrobromic  ether  passed 
through  a  glass  tube  at  a  low  red  heat  is  resolved  into  ethylene 
and  hydrobromic  acid  gas.  2.  It  burns  with  difficulty,  but  with 
a  beautiful  green  flame,  which  does  not  smoke,  a  strong  odor 
of  hydrobromic  acid  being  at  the  same  time  evolved.  3.  It  is 
not  decomposed  b.y  nitric  acid,  oil  of  vitriol  or  potassium. 
4.  With  ammonia  it  yields  hydrobromate  of  ethylamine. 

The  hydrobromic  ether  or  bromide  of  ethyl  was  discovered 
by  Serullas,  in  1827,  but  received  no  special  attention  until  Dr. 
Thomas  Nunnelly,  of  Leeds,  reported  some  experiments  made 
with  it  on  animals  in  1849.  Dr.  Nunnelly  brought  the  subject 
again  before  the  profession  by  a  paper  read  at  the  meeting  of 
the  British  Medical  Association  in  1865,  in  which,  speaking  of 
it  in  conjunction  with  another  aneesthetic,  he  said  he  had  for 
some  time  employed  the  one  or  the  other  in  all  the  principal 
operations  at  the  Leeds  Greneral  Eye  and  Ear  Infirmary.  This 
was  at  a  time  when  chloroform  held  such  complete  sway  in 
England  that  no  importance  was  attached  to  Nunnelly' s  experi- 
ence or  experiments.  He  had  no  one  to  follow  him  in  using  it ; 
and  we  hear  no  more  of  it  until  1876,  when  some  experiments 
were  made  with  it  in  France,  by  Rabuteau,  on  the  lower  ani- 
mals, but  evidently  without  a  knowledge  of  the  fa(^t  that  this 
had  been  done  previously  in  England  by  Nunnelly. 

The  writer  then  took  the  agent  up  without  the  knowledge* of 
the  experiments  of  Dr.  Nunnelly.  He  had  it  made  in  Phila- 
delphia by  Professor  Remington,  and  with  two  friends  began 
experimenting  in  September,  1877,  using  it  first  on  himself  and 
then  upon  his  patients. 

Pliysiolog-ical  Action  of  Bromide  of  Ethyl. 

The  physiological  action  of  bromide  of  ethjd  has  been  studied 
by  the  author  and  other  observers.  A  peculiarity  that  has  been 
noted  is  a  tendency  for  sensibility  to  be  lost  and  pain  relieved 
before  consciousness  has  been  completely  destroyed,  so  that 
short  operations  can  be  done  at  that  stage.  There  is  not  always 
complete  relaxation  of  the  muscles,  as  in  the  use  of  ether.     If 


PHYSIOLOGICAL  ACTION  OF  BROMIDE  OF  ETHYL.   229 

the  bromide  of  ethyl  is  impure,  such  as  was  employed  in  the 
Jefferson  Medical  College  Hospital  by  the  late  Dr.  Levis  and 
others  (see  p.  235  for  chemical  examinations),  general  tetanus 
and  even  opisthotonus  with  increase  of  haemorrhage  must  have 
occurred  from  free  phosphorus,  as  no  such  results  have  been 
noticed,  as  is  stated  by  Dr.  John  H.  Brinton  [Therap.  Gaz., 
V.  3),  which  has  followed  the  operation  ;  this  has  not  been  noted 
by  any  other  surgeon  that  we  can  find  any  record  of. 

The  subject  has  been  also  studied  by  Schneider,  Aboneje, 
Thornton  and  Maxwell  {Therap.  Gaz.,  1892)  and  by  Wood 
{Theraps.,  9th  ed.).  Schneider  states  that  the  arterial  pressure 
does  not  fall  until  very  late  in  the  bromide  narcosis,  and  that 
death  takes  place  always  through  arrest  of  respiration.  In 
those  statements  he  is  in  accord  with  results  obtained  by 
Aboneje  {Wiener  KlmiJc,  1891,  Heft.  1),  which  agrees  with  our 
own  experiments,  while  Wood  {op.  cit. )  endeavors  to  show  that 
the  arterial  pressure  occurs  very  early  and  increases  steadily 
with  persistent  inhalation  (beyond  the  point  of  true  anaesthe- 
sia). This  his  young  friends  (Thornton  and  Maxwell)  endeavor 
to  confirm,  but  we  think  not  with  success.  We  feel  sure  that 
the  bromide  of  ethyl,  in  its  action,  is  not  at  all  like  chloroform, 
and  we  fear  that  Dr.  Wood  has  not  had  very  pure  specimens 
of  the  drug  for  experimentation.  For  he  states:  "It  is  possi- 
ble that  this  difi"erence  of  result  has  depended  upon  some  of 
the  bromide  of  ethyl  used  (we  add,  by  himself  and  friends) 
being  impure." 

In  few  instances,  recently,  the  use  of  this  anaesthetic  has  been 
attended  with  persistent  vomiting  and  free  secretion  of  mucus 
owing  to  impurities,  though  in  the  thousands  of  cases  in  which 
it  has  been  employed,  chiefly  in  Philadelphia,  in  not  one  single 
instance  has  it  caused  cerebral  trouble,  or  any  of  the  symptoms 
produced  by  the  action  of  free  bromine.  We  have  experimented 
upon  frogs,  cats,  dogs,  rabbits  and  various  other  animals  by 
subjecting  them  to  an  atmosphere  highly  charged  with  the  vapor 
of  hydrobromic  ether,  and  in  rare  instances  were  there  the 
effects  described  above. 

In  some  recent  experiments  on  animals  we  crowded  four 
ounces  upon  a  dog  by  means  of  a  tin  inhaler,  until  he  became 


230  ARTIFICIAL    ANESTHESIA. 

apparently  dead,  with  no  perceptible  action  of  the  heart  or 
lungs ;  but  the  expression  of  his  eye  was  clear  and  the  pupil 
was  dilated,  while  there  was  no  secretion  from  the  eyes  or  nos- 
trils. The  apparatus  was  removed  in  the  space  of  four  min- 
utes, and  he  was  exposed  to  the  air,  when  at  once  he  began  to 
breathe,  and  by  the  end  of  six  minutes  he  had  entirely  recov- 
ered consciousness.  The  dog  did  not  seem  much  inclined  to 
move  for  ten  or  twelve  minutes  afterwards.  While  this  dog 
was  only  partially  under  the  influence  of  this  anaesthetic,  having 
at  first  caught  the  inhaling  apparatus  between  his  teeth,  there 
was  a  good  deal  of  rigidity  and  slight  tetanic  movements  of  the 
extremities,  but  this  was  overcome  by  the  free  use  of  the  ether. 
Had  we  been  using  chloroform,  just  before  he  would  have  come 
completely  under  its  full  influence,  he  would  have  died.  Nu- 
merous dogs  were  lost  every  season  when  experimenting  upon 
them,  so  that  now  chloroform  alone  is  rarely  employed  in  the 
laboratory  for  experimental  purposes. 

Vernuil,  at  the  meeting  of  the  Societe  de  Chirurgie,  stated 
that  one  patient,  a  woman,  to  whom  he  had  given  the  vapor  of 
ethyl  bromide,  was  asleep  in  an  instant ;  and  Terrillon  stated 
that  anaesthesia  may  be  produced  in  less  than  a  minute.  In  our 
own  experiments,  the  shortest  time  necessary  for  primary  anaes- 
thesia was  thirty  seconds. 

The  bromide  of  ethyl  is  costly,  from  the  great  care  required 
in  its  preparation  ;  and  the  great  demand  for  it  has  caused  many 
imitations  to  be  placed  on  the  market.  The  importance  of  its 
purity  was  at  first  so  little  understood  that  the  original  manu- 
facturers did  not  take  sufiicient  time  to  purify  it. 

Mode  of  Employment. 

1.  All  tight-fitting  garments  in  and  about  the  neck  and  chest 
should  be  loosened  and  the  patient  lay  down. 

2.  The  ethyl  vapor  must  be  inhaled  at  first  with  atmospheric 
air.  The  best  form  of  inhaler  is  a  thick  towel,  folded  in  the 
form  of  a  cone,  closed  at  the  apex  with  a  large  pin  ;  between 
the  folds  of  the  towel  place  a  sheet  of  newspaper  or  rubber. 
The  base  of  the  cone  must  be  wide  enough  to  include  both 
mouth  and  nose. 


MODE    OF    EMPLOYMENT.  231 

3.  Instruct  the  patient,  in  advance,  to  make  deep  and  long 
inspirations.  In  the  cone  place  about  from  75  to  150  drops  for 
the  adult,  and  50  to  100  for  the  infant,  by  measure.  At  once 
cover  the  nose  and  mouth  with  it,  and  do  not  remove  the  cone 
until  anaesthesia  is  produced. 

The  anaesthetic  sleep  will  not  last  more  than  from  two  to 
three  minutes.  The  patient  retains  the  usual  healthy  color  of 
lips  and  skin,  and  the  pulse  first  becomes  rapid,  then  slower  and 
stronger,  as  the  narcosis  becomes  profound.  The  patient,  as  a 
rule,  awakens  suddenly  and  completely,  but  if  there  is  nausea 
or  much  agitation  it  is  best  for  him  to  remain  quiet  and  in  a 
horizontal  posture  for  some  time. 

Dr.  Koellicker,  in  some  recent  observations,  recommends  the 
bromide  of  ethyl  in  a  great  number  of  small  operations  in 
surgery.  His  method  is :  place  the  patient  decubitis  dorsal, 
and  gives  careful  direction  in  examining,  in  every  case,  the 
heart. 

He  employs  a  mask  of  thin  rubber  and  a  la5'er  of  flannel  from 
ten  to  fifteen  grammes  for  the  adult  and  five  to  ten  for  the  child. 
You  pour  a  few  drops  of  bromide  of  ethyl,  and  in  a  few  sec- 
onds the  whole  quantity ;  the  anaesthesia  takes  place  in  the 
course  of  one  minute  ;  we  tell  the  patient  to  hold  the  arm  up, 
and  then  the  operation  can  be  performed. 

We  did  not  often  advise  that  bromide  of  ethyl  should  be 
resorted  to  in  protracted  operations,  and  we  never  have  em- 
ployed it  in  any  case  longer  than  forty  minutes,  and  have 
never  used  more  than  four  ounces  of  the  pure  ether  in  any  one 
case. 

In  more  than  one  hospital  they  were  furnished  an  ethyl  bro- 
mide that  was  impure.  It  was  prepared  with  phosphorus, 
bromine  and  alcohol.  The  phosphorus  employed  was  impure ; 
it  gave  out  hydrogen  phosphide,  which  caused  the  alliaceous 
odor  noticed  in  patients  who  had  been  anaesthetized  by  this 
method.  The  ethyl  bromide  should  be  prepared  with  sulphuric 
acid,  ethj'lic  ether  and  potassium  bromide ;  this  method  gave  a 
much  purer  product.  Ethyl  bromide  contained  then  a  larger 
proportion  of  ethylic  ether,  and  was  preferable  to  that  used  in 
the  hospitals.     M.  Bazy  had  observed  that  vomiting  rarely  fol- 


232  ARTIFICIAL    ANAESTHESIA. 

lowed  anaesthetics  with  ethyl  bromide  alone,  but  thought  it  not 
so  in  mixed  anaesthetics,  as  with  the  latter  method  in  the  case 
of  a  child  he  had  observed  abundant  vomiting  on  the  patient's 
return  to  consciousness.* 

The  most  recent  views  of  Professor  Wood  on  the  subject  of 
bromide  of  ethyl  is  as  follows:    "At  least  one,  and  probably 
more,  deaths  have  been  produced  by  the  substitution  of  the 
bromide  of  ethjdine  for  the  bromide  of  ethyl."     (See  Therap. 
Monatch.,  1889,  Vol.  III.) 

Dr.  Grilles  claims  {Berlin  Klin.  Wochensh.,  Vol.  XXIX., 
1892)  there  were  given  in  Grermany  during  three  years  twenty 
thousand  administrations  without  a  single  fatal  result  on  record 
in  which  it  has  been  proved  that  a  chemically  pure  bromide  has 
been  administered. 

Dr.  Woodf  concludes  as  follows  :"  Our  present  knowledge 
appears  to  indicate  that  an  absolutely  pure  bromide  of  ethyl  i& 
a  proper  substance  for  the  production  of  brief  anaesthesia. 
This  is  all  that  the  author  of  this  work  ever  claimed  for  it," 
(See  3d  Edition,  article  "Ethyl  Bromide.")  Magill  advocates 
the  rapid  induction  of  anaesthesia  by  means  of  ethyl  bromide 
and  the  substitution  of  chloroform  to  maintain  unconsciousness. 
He  maintains  that  ethyl  bromide  cannot  produce  primary  syn- 
cope from  naso-pharyngeal  reflex,  that  it  stimulates  cardiae 
action  and  is  less  toxic.  + 

The  ethyl  bromide  is  given  on  a  folded  towel,  and  after  three 
or  four  inhalations  the  patient  loses  all  sense  of  touch  or  pain, 
but  is  still  conscious.  Complete  unconsciousness  is  induced  in 
about  one  minute  and  chloroform  substituted.  In  spite  of 
recorded  fatalities  from  ethyl  bromide,  Magill  believes  it  to  be 
a  safe  agent  when  pure,  and  holds  that  some  deaths  assigned  to 
it  were  really  induced  by  other  causes. 

Ethyl  Bromide  as  an  Anaesthetic. 

The  Gazette  Medicale  de  Paris  for  May  12,  1894,  contains  a 
report  of  the  proceedings  of  a  meeting  of  the  Academy  de 

*  New  York  Med.  Journal,  June  9.  1894,  p.  733. 

t  Therapeutics,  H.  C.  Wood,  9th  Ed.,  p.  151, 

X  Internat.  Med.  Mag.,  June,  1894.  * 


RECENT    OBSERVATIONS.  233 

Medicine,  at  which  M.  Suarez  de  Mendoza,  of  Anders,  related 
the  case  of  a  woman  who  had  died  suddenly  during  the  first 
inhalation  of  ethyl  bromide.  The  death,  he  said,  should  be 
attributed  to  cardiac  syncope,  provoked  by  the  action  of  the 
vapors  of  this  anaesthetic  on  the  ends  of  the  nasal  nerve  (details 
not  given  of  operation  or  post-mortem).  The  same  journal 
publishes  a  paper  on  the  subject  of  ethyl  bromide  as  an  anaes- 
thetic, which  was  read  before  the  Societe  de  Chirurgie  by  M. 
Terrier.  The  author  remarks  that  he  has  employed  ethyl  bro- 
mide alone  or  mixed  with  chloroform  for  a  long  time,  both  in 
hospital  and  in  his  private  practice.  He  had  such  variable 
results  from  the  use  of  this  anaesthetic  that  he  felt  it  was  his 
duty  to  analyze  several  specimens,  and  found  them  impure. 

Some  Recent  Observations  on  Mixtures  of  Bromide 

of  Ethyl. 

"Eschawzier,"  an  assistant  to  a  dentist  of  Brooklyn,  had 
the  misfortune  to  lose  a  patient  from  this  mixture  of  bromide 
of  ethyl  and  oil  of  roses,  so-called  soporative,  after  the  extrac- 
tion of  a  tooth.  He  had  no  assistant,  and  operated  in  the 
ordinary  manner.  The  lady  recovered  from  the  anaesthetic  and 
shortly  after  was  attacked  with  syncope  and  choked.  Had  he 
elevated  her  feet  and  depressed  her  head,  or  drawn  out  the 
tongue,  all  would  have  been  well,  but  nothing  was  done,  as  no 
medical  man  was  present.  The  cause  of  death  was  stated  to 
the  jury  as  asphyxia  and  pulmonary  congestion.  She  was 
stated  to  have  had  a  fatty  heart,  but  as  there  was  no  post-mor- 
tem we  do  not  know  how  the  non-medical  man  arrived  at  this 
'  conclusion.  But  this  was  for  the  jury,  who  exonerated  the 
dentist's  assistant,  but  wisely  recommended  that  in  all  doubtful 
cases  the  patient  should  be  examined  by  a  competent  medical 
man  before  the  anaesthetic  be  administered. 

This  is  a-  lesson  to  those  who  employ  mixtures,  which  are 
never  as  safe  as  the  agent  alone,  which  should  be  well  studied 
by  the  dental  or  medical  man  before  being  employed. 

We  regret  to  learn  that  under  the  term  vitalized  air  there  are 
found  mixtures  of  ethyl  bromide,  ether,  alcohol  and  even  chlo- 

16 


234  ARTIFICIAL    ANAESTHESIA. 

roform.  These  mixtures  are  termed  "proprietary  anaesthetics." 
Our  attention,  says  the  editor  of  the  Dental  Cosmos,  has  again 
been  called  to  this  subject  by  a  correspondent,  who  enclosed  a 
circular  announcing  a  "new  discovery  for  producing  natural 
sleep  at  will;  safe  and  efficient  for  extracting  teeth  without 
pain  or  danger;  indorsed  by  the  leading  medical  journals  in 
Europe  and  America. ' ' 

The  proprietor  of  this  wonderful  agent  claims  that  it  was 
discovered  after  years  of  labor  and  research;  that  since  1864 
he  had  been  constantly  on  the  alert  for  some  agent  that  would 
be  more  efficient,  safe  and  economical  than  nitrous  oxide.  He 
appends  statistics  showing  its  relative  economy,  and  testi- 
monials as  to  its  safety  and  efficiency.  He  claims  that  he  was 
led  to  the  investigations  which  resulted  in  the  discovery  of  this 
new  anaesthetic  from  the  conviction  that  "progressive  science 
devises  means  for  producing  natural  sleep  at  will,"  and  he 
therefore  determined  to  investigate  and  discover,  if  possible, 
some  agent  that  would  not  be  open  to  the  objections  which  ap- 
pertain to  chloroform,  ether  and  nitrous  oxide  gas,  all  of  which 
he  considers  unsafe  because  they  produce  congestion  of  the 
brain,  and  death  is  likely  to  result  from  such  abnormal  condi- 
tion; and  that  the  new  anaesthetic  produces  natural  sleep  with- 
out congestion,  and  is  therefore  absolutely  free  from  danger, 
and  that  "heart  disease,  pregnancy,  lactation,  menstruation, 
kidney  troubles  and  old  age  are  no  drawbacks  in  its  administra- 
tion." The  discoverer  of  this  new  anaesthetic  has  given  it  the 
name  of  "  soporative,"  the  word  being  derived  from  the  Latin 
soporo,  meaning  natural  sleep,  as  we  are  informed  in  the 
circular. 

Realizing  at  once  the  value  which  an  agent  of  this  character 
would  have  in  the  practice  of  medicine  and  dentistry,  we  pro- 
cured a  bottle  direct  from  the  proprietor,  at  a  cost  of  five  dol- 
lars, at  once  submitted  it  for  analysis,  and  have  received  the 
following  report  thereon  : 

Philadelphia,  March  29,  1886. 
To  the  late  J.  W.  White,  M.D., 
Dear  Sir:  The  sample  of  "Soporative"  received  from  you 


RECENT    OBSERV^ATIONS.  235 

on  the  24th  inst.  has  been  examined.  It  is  Bromide  of  Ethyl, 
flavored  with  rose,  and  containing  distinct  traces  of  alcohol,  aa 
follows  : 

Bromide  of  Ethyl,     .         .         .       99.13  per  cent. 

Alcohol  and  Oil  of  Rose,  .        .  .87  per  cent. 

]00.00 
Yours  truly, 

Henry  Trimble, 
Professor  of  Analytical  Ghemisttnj  in  the 
Philadelphia  College  of  Pharmacij. 

There  are  still  dangerous  mixtures  kept  up  to  the  present  day 
by  ad%^ertising  in  our  first-class  dental  journals. 

The  following  are  examples  of  impure  specimens  of  pure 

ethyl  bromide  : 

;^o.  7.— The  sample  is  first  left  in  contact  with  the  sodium 
amalgam  alone  after  color  reactions  are  obtained,  the  water  is 
added.  This  sample,  we  may  remark,  was  furnished  Dr.  Wil- 
ham  Brodie,  of  the  Therapeutic  G-azette,  and  Dr.  J.  Marion 
Sims.  It  is  a  portion  of  that  employed  by  this  distinguished 
surgeon  in  the  fatal  case  with  the  details  of  which  the  profes- 
sion is  so  famihar  in  our  third  edition. 

Professor  Jungk  received  an  additional  consignment  of  various 
commercial  brands  of  bromide  of  ethyl.  As  the  time  for  mak- 
ing further  tests  was  too  limited  to  take  in  hand  more  than  a 
single  sample,  he  selected  for  the  purpose  one  purporting  to 
have  been  used  by  Dr.  Levis,  of  Philadelphia,  in  the  fatal  case 
which  occurred  in  his  practice  from  the  eifects  of  this  anaes- 
thetic, which  sample  consisted  of  about  two  fluid  ounces,  and 
was  contained  in  a  bottle  with  the  name  "Jefferson  Medical 
College  Hospital"  blown  in  the  glass.  The  reaction  obtained 
with  this  sample  resembles  very  much  that  of  No.  T,  with  addi- 
tional formation  of  a  turbidity,  which  is  not  soluble  in  nitric 
acid.  The  reaction  of  this  sample,  as  well  as  those  obtained 
with  Nos.  1,  4,  6  and  7,  demonstrate  conclusively  their  entire 
unfitness  for  the  purpose  of  inhalation.  No  records  of  the 
deaths  from  ethyl  bromide,  have  been  transferred  from  the  third 


236  ARTIFICIAL    ANESTHESIA. 

edition,  but  every  case  since  1890  has  been  published  by  the 
author. 

Dr.  E.  E.  Montgomery's  Opinion  on  the  Value  of 
Ethyl  Bromide  in  Obstetrics. 

"We  have  used  the  drug  in  twenty-nine  cases,  and  have  be- 
come so  well  pleased  with  its  action  as  to  regard  it  a  necessity 
in  the  practice  of  obstetrics. 

"In  the  use  of  a  new  anaesthetic,  and  one  which,  from  its  re- 
cent use,  must  necessarily  be  regarded  with  suspicion,  we  have 
been  extremely  careful  in  observing  and  noting  its  effects. 

"  Of  these  cases,  eight  were  primiparae,  and  twenty-one  multi- 
parae ;  in  the  former,  delivery  was  completed  five  times  with 
forceps,  in  the  latter  eleven  times. 

"  Analyzing  these  cases  further,  discloses  that : 
In  5,  ethyl  was  not  given  until  the  forceps  were  applied. 
In  3,  labor  was  completed  naturally,  where  previous  labors 

were  instrumental. 
In  1,  former  labor  was  also  instrumental. 
In  3,  labor-pains  were  weak  before,  and  after,  administra- 
tion of  the  drug. 
In  2,  pains  were  weak,  but  strength  greatly  increased  after 

its  administration. 
In  2,  the  foetus  presented  with  vertex  in  R.  0.  P.  position. 
In  1,  delivery  followed  by  uterine  inertia,  inversion  and 

haemorrhage. 
In  1,  foetus  still-born. 
In  1,  child  died  same  day,  in  convulsions. 
In  1,  child  died  second  day,  of  cyanosis. 
"  In  the  presentation  of  any  anaesthetic  for  general  obstetric 
use  the  profession  have  the  right  to  demand  that  it  shall  be 
shown  to  be  absolutely  safe  for  mother  and  child  ;  that  it  will 
not  cause  uterine  inertia,  thus  increasing  the  danger  of  post- 
partum haemorrhage,  nor  induce  acute  inflammatory  conditions 
in  the  organs,  by  which  it  is  eliminated,  complicating  the  puer- 
peral stage. 


BROMIDE    OF    ETHYL.  237 

Details  of  Cases  in  Our  Last  Edition. 

BEFORE   ADMINISTRATION.  AFTER  ADMINISTRATION. 

Time  of  beginning.  Length.  Time  of  beginning.  Length. 

ll^  13",  30'"  P.M.  30"'  ll^  40",  45'"  30'" 

IV,  15",  45'"  30'"  ll^  42",  30'"  1" 

11^,  19"  1",  30'"  ll^  44",  30'"  45'" 

ir,  21",  20"'  1"  ir,46",  30'"  1" 

11^  22",  45'"  30'"  ll^  49",  15'"  1" 

11^25",  20'"  1"  ir,  52"  30'" 

11^,  27"  30"'  ll^  54"  1" 

11^,  28",  45'"  2",  30'"  11^  56"  1.15 

Total  T.  17",  45"'     Total  L.  8"  T.  T.  16",  30'"  T.  L.  7" 

"We  have  noticed  a  marked  want  of  uniformity  in  the  action 
of  diflferent  preparations  of  this  drug.  Some,  procured  for  use 
in  the  Philadelphia  Hospital,  had  an  unpleasant  irritating  odor, 
and  were  slow  in  producing  the  angesthetic  effect.  To  this  fact 
we  are  inclined  to  ascribe  the  want  of  action  experienced  by 
Miiller  in  a  number  of  his  cases.  We  have  been  in  the  habit 
of  specif j^ing  either  Merck's  or  Parke,  Davis  &  Co.,  when  pro- 
curing it,  as  we  have  invariably  found  their  preparations  of 
the  drug  with  a  pleasant  odor,  and  reliable  in  action. 

"We  feel  that  the  experience  derived  from  our  own  cases,  to- 
gether with  the  commendation  of  other  experimenters,  justify 
us  in  urging  upon  the  profession  a  more  extended  trial  of  this 
agent  in  alleviating  the  sufferings  of  the  most  trying  period  of 
maternal  life." 

Bromide  of  Ethyl. 

The  following  letter  will  show  that  Dr.  Montgomer>^  still 
retains  his  faith  in  the  use  of  a  pure  bromide  of  ethyl,  which  he 
has  now  used  for  six  years  with  the  due  care  and  caution  with 
which  every  anaesthetic  should  be  thus  employed  : 

"Philadelphia,  February  11,  1896. 
"  Laurence  TuRNBULL,  M.D., 

"255  South  Seventeenth  Street. 
"  My  Dear  Doctor:  Your  letter  of  February  10th  is  at  hand. 
I  find  no  reason  to  lose  faith  in  the  value  of  bromide  of  ethyl 


238  ARTIFICIAL    ANAESTHESIA. 

as  an  anaesthetic  for  short  operations  and  examinations.     I  am 
using  it  constantly. 

"  Very  sincerely  yours, 

"E.  E.  Montgomery, 

''''Professor  of  Clinical  Gynaecology^ 

'"^Jefferson  Medical  College^  Philadelphia.'" 

Anaesthesia  by  tlie  Bromide  of  Ethyl.* 

The  bromide  of  ethyl  has  been  extensively  employed  of  late 
by  the  dentists  of  Germany  and  in  the  minor  operations  in 
surgery  of  short  duration.  It  should  be  administered  in  the 
following  manner: 

While  the  patient  is  becoming  accustomed  to  the  odor  of  the 
anaesthetic,  no  external  impression  must  be  given,  nor  noise 
made  by  those  around  him.  Skinner's  apparatus  should  be 
used,  lined  with  rubber  and  covered  with  a  piece  of  flannel, 
upon  which  is  poured  a  few  drops  of  the  anaesthetic,  so  as  to 
exclude  all  air.  The  anaesthetic  requires  from  fifty  to  sixty 
seconds,  and  lasts  three  minutes. 

The  requisite  amount  is  from  five  to  ten  grammes  for  an  in- 
fant and  ten  to  fifteen  grammes  for  an  adult,  with  no  unpleasant 
results.  This  anaesthesia  has  been  found  very  convenient  for 
incisions  in  abscesses,  etc.,  tenotomies  of  tendons,  the  applica- 
tion of  the  thermo-cautery,  extirpation  of  small  tumors,  and 
for  quickly  emptying  a  tubercular  deposit. 

Bromide  of  ethyl  is  a  nervous  sedative,  and  is  employed  in 
epilepsy,  hysteria,  etc.  Dose,  for  internal  use,  five  to  thirty 
drops  in  sugar,  or,  better,  in  capsules  ;  must  be  kept  from  light, 
heat  and  air  ;  and,  to  obtain  pure,  ordered  in  sealed  tubes.  Be 
sure  not  to  order  bromide  of  ethylene,  which  is  poisonous  if 
employed  in  spray  or  by  inhalation,     Dose,  150-300  M. 

*  By  Dr.  Kolliker  (Centralblatt  fiir  Chirurgie.  No.  20.  p.  385, 1891). 


PART    FOURTH. 


CHAPTER    VIII. 

ChloToform— Dichlorinated  Chloride  of  Methyl— Terchloride  of 
Formyl  (CHClsj. 

Cbloroform. 

The  ordinary  method  of  preparing  chloroform  is  by  the  distil- 
lation of  alcohol  and  chloride  of  lime  ;  but  owing  to  the  heavy 
duty  upon  alcohol  the  following  methods  will  show  that  it  can 
be  manufactured  at  less  cost.  One  of  these  new  processes  con- 
sists in  the  substitution  of  wood  alcohol  (this  is  one-third  less  in 
price  than  grain  alcohol). 

When  wood  is  subjected  to  destructive  distillation,  the  result 
is  pyroligneous  acid  and  pyroxylic  spirit,  commonly  called  wood 
alcohol.  The  latter  is  separated  in  a  very  impure  state,  redis- 
tilled with  lime,  and  then  manufactured  into  chloroform,  and  is 
purified  in  the  ordinary  way  with  chloride  of  Hrae  and  sulphuric 
acid.  The  manufacture  of  chloroform  from  pure  wood  alcohol 
is  not  entirely  new,  but  the  value  of  the  patent  consists  in  the 
fact  of  being  able  to  use  the  alcohol  in  a  crude  or  intermediate 
state  before  it  is  separated  from  the  pyroligneous  acid  and  the 
other  liquid  constituents  of  wood,  thus  reducing  the  cost  to  a 

minimum. 

Chloroform  prepared  from  wood  spirit  is  specifically  lighter, 
and  has  at  times  an  empyreumatic  odor  from  acids  or  chlorinated 


240  ARTIFICIAL    ANESTHESIA. 

oils,  and  gives  rise,  when  inhaled,  to  unpleasant  sensations, 
with  prostration  and  headache.  Many  chloroform  accidents  are 
doubtless  due  to  impurities  in  the  drug.  Sleep  is  obtained  with 
difficulty,  and  is  disturbed  in  character.  In  some  cases,  to  in- 
duce sleep,  the  attempt  has  had  to  be  given  up,  as  the  impure 
chloroform  only  produced  irritation  of  the  lungs  and  stomach, 
inducing  vomiting,  etc. 

Ad  Improved  Chloroform. 

The  new  process  for  the  manufacture  of  chloroform  we  quote 
from  no  less  an  authority  than  Sadler :  * 

"The  raw  material  from  which  chloroform  is  made  is  the  gray 
acetate  of  lime.  While  this  is  distinctly  purer  than  brown  ace- 
tate, it  still  contains  both  moisture  and  tarry  matter.  To  free 
it  from  these  and  to  raise  the  percentage  of  actual  acetate  of 
lime,  it  is  carefully  roasted  before  being  submitted  to  dry  distil- 
lation. This  roasting  forms  the  subject  of  patent  No.  393.079, 
issued  to  Grustav  Rumpf,  of  Frankfort,  Germany,  and  assigned 
to  Roessler  and  Hasslacher,  of  New  York.  It  is  done  in  a 
series  of  three  slightly  inclined  cylindrical  retorts,  in  which  the 
material  is  continually  pushed  forward  by  revolving  blades.  The 
gray  crude  acetate  is  dropped  in  and  passes  along  the  length  of 
the  upper  retort,  until  it  drops  upon  the  blades  which  revolve 
in  the  second  retort,  and,  passing  along  this,  is  dropped  into  the 
third  or  lowest  retort,  from  which  it  issues  and  is  collected  in 
suitable  vessels.  By  this  continuous  rotating  process  the  crude 
material  can  be  purified  without  notable  decomposition  of  the 
true  acetate. 

"The  patentee  claims  that  'in  the  process  of  subjecting  ace- 
tates in  a  closed  vessel  to  heat  applied  externally  to  the  vessel 
for  distilling  acetone  from  the  acetates,  the  desired  slowness  and 
uniformity  of  temperature  may  be  secured  by  stirring  the  ace- 
tate, so  that  all  portions  of  the  mass  will  be  subjected  to  the 
heat  resulting  from  direct  contact  with  the  bottom  of  the  vessel, 
and  by  admitting  free  steam  from  time  to  time  into  direct  con- 

*  Pharmaceutical  Record,  August  19, 1889,  Samuel  P.  Sadler. 


'       AN  IMPROVED  CHLOROFORM.         241 

tact  with  the  acetates  in  case  of  any  undesirable  rise  in  temper- 
ature within  the  vessel. '  ' ' 

This  is  effected  by  mechanical  agitation  provided  for  by  the 
paddles  which  rotate  around  the  vertical  central  axis.  Steam 
is  admitted  by  one  of  the  openings  above,  while  the  products  of 
distillation  pass  off  by  another  opening  in  the  top  of  the  retort. 
The  crude  acetone  distillate  so  obtained,  while  richer  than  be- 
fore in  real  acetone,  still  contains  oily  distillation  products  and 
much  water  from  condensed  steam.  In  this  dilute  state  it  is 
treated  with  milk  of  lime  to  remove  the  higher  ketones  and 
other  compounds.  It  is  then  distilled  from  a  large  plain  still, 
and  the  fractions  rich  in  acetone  passed  to  a  column  still,  where 
it  is  rectified  until  it  becomes  almost  if  not  quite  anhydrous. 
In  practice,  two  column-still  rectifications  are  carried  out,  one 
after  the  other,  so  that  the  pure  acetone  shows  99°  or  100°  by 
the  alcoholometer.  It  is  now  fitted  for  use  in  the  direct  manu- 
facture of  chloroform.  The  process  and  form  of  apparatus  for 
most  successfully  carrying  out  this  chloroform  manufacture,  con- 
stitute the  subject  of  United  States  patent  No.  383,992,  also 
issued  to  Gr.  Rumpf  and  assigned  to  Roessler  and  Hasslacher. 
The  patentee  first  states,  that  in  order  to  get  the  full  yield  of 
chloroform,  it  is  necessary  to  take  a  much  larger  proportion  of 
bleaching  powder  than  that  given  in  "Watts'  Dictionary  of 
Chemistry,"  Yol.  1,  page  918,  and  states  that  for  58  pounds  of 
acetone  at  least  600  pounds  of  chloride  of  lime  of  thirty-five  per 
cent,  available  chlorine  are  necessary.  The  yield  will  then  be 
from  one  hundred  and  fifty  to  one  hundred  and  eighty  per  cent, 
of  the  weight  of  acetone  employed  instead  of  about  thirty-three 
per  cent. 

The  still  having  been  filled  to  a  proper  height  with  water, 
the  charge  of  bleaching  powder  is  introduced,  and  the  man-hole 
closed  with  cement.  The  agitators  having  been  started  by 
means  of  the  revolving  shaft,  the  acetone,  previously  diluted, 
is  pumped  in  gradually.  As  it  enters,  it  rises  and  reacts  with 
the  bleaching-powder  solution,  and  the  chloroform  produced, 
distilled  spontaneously  from  the  delivery  tube,  passes  through 
the  condenser,  and  is  collected  under  water.     The  introduction 


242  ARTIFICIAL    ANAESTHESIA.  * 

of  diluted  acetone  is  to  be  effected  at  intervals  only,  otherwise 
some  will  distill  over  unchanged,  or  the  reaction  will  become  too 
violent,  and  much  frothing  ensue.  When  the  delivery  of 
chloroform  begins  to  slacken,  steam  is  gradually  introduced  to 
heat  up  the  mixture  and  drive  over  the  last  portion  of  chloro- 
form which  remains.  The  contents  of  the  still  are  then  dis- 
charged into  a  drain.  They  consist  of  very  dilute  calcium 
acetate  solution  mixed  with  calcium  hydrate  and  calcium  chlo- 
ride. 

The  reaction  for  this  production  of  chloroform  from  acetone 
seems  to  be  simply 

2C3Heo  +  GCaOCl,  =  2COI3H  +  CalC^HsOOa  +  2Ca(OH)2 
4-  3CaCl2.  This  would  demand  one  equivalent  of  chloroform 
for  one  of  acetone  used,  or  206  parts  of  chloroform  by  weight 
reckoned  on  the  weight  of  the  acetone.  In  practice,  180  parts 
are  usually  obtained,  although  200  parts  have  actually  been  ob- 
tained at  times. 

The  chloroform  obtained  is  quite  free  from  the  chlorinated 
side  products  w^hich  often  accompany  the  chloroform  made 
from  impure  alcohol.  It  is,  nevertheless,  thoroughly  purified 
by  treatment  with  sulphuric  acid  and  careful  washing,  and  is 
then  brought  exactly  to  the  United  States  Pharmacopoeia 
standard. 

Commercial  chloroform  when  obtained  is  a  transparent, 
heavy  liquid  containing  ninety-eight  per  cent,  of  chloroform, 
frequently  containing  hydrochloric  acid,  chlorine,  and  foreign 
chlorine  compounds,  with  traces  of  arsenic  as  impurities.  It  is 
therefore  unfitted  to  use  as  a  medicine,  or  as  an  anaesthetic 
agent,  until  purified. 

Chloroformum  Purificatuni— Purified  Chloroform. 

(CHCI3;  119.2— CH2CI3;  119.2.) 

After  careful  purification,  by  means  of  redistillation,  in  con- 
tact with  sulphuric  acid,  carbonate  of  sodium,  lime,  potash, 
alcohol  and  water,  it  is  then  ready  for  use.  Chloroform,  in  its 
pure  state,  is  a  heavy,  clear  liquid,  having  a  specific  gravity  of 


PURIFIED    CHLOROFORM.  243 

1.49°.  It  has  a  characteristic,  pleasant,  and  ethereal  odor,  a 
burning  sweet  taste,  and  a  neutral  reaction.  It  dissolves  in 
alcohol  and  ether  in  all  proportions,  but  only  mixes  with  water 
in  small  proportions,  and  will,  after  a  time,  sink  to  the  bottom 
of  such  mixtures  in  clear  globules,  owing  to  its  being  so  much 
heavier.  It  communicates  its  sweetish  taste  to  water.  Dose, 
3  to  10  min.  given  in  capsules,  or  mixed  with  alcohol  as  the 
spiritus  chloroform,  1  volume  in  20.  Dose,  20  to  60  min.,  or  in 
the  mistura  chloroform i — chloroform  8,  camphor  2,  fresh  yolk 
of  egg  10,  water  80.  Dose,  tablespoonful.  If  a  few  drops  be 
permitted  to  evaporate  from  blotting  paper,  no  stain,  or  no 
foreign  odor  should  be  perceptible  after  the  odor  of  chloroform 
ceases  to  be  recognized.  When  applied  to  the  skin,  chloroform 
evaporates  rapidly,  and  produces  a  feeling  of  cold.  When  the 
evaporation  is  prevented,  it  passes  through  the  epidermis,  and 
acts  as  an  irritant  to  the  inner  skin,  producing  rubefaction  and 
local  anaesthesia.     (See  article  on  Local  Anaesthetics. ) 

No  chloroform  should  be  used  for  anaesthetic  purposes  which 
does  not  comply  with  the  following  requirements  : 

1st  test.  When  dropped  in  distilled  water,  there  should  be 
transparent  globules  with  no  milky  appearance. 

2d.  Chloroform  should  have  an  agreeable  odor. 

3d.  It  should  not  redden  blue  litmus  paper. 

4th.  When  added  to  a  solution  of  nitrate  of  silver,  it  should 
not  form  a  precipitate,  nor  even  cause  cloudiness. 

5th.  Test  with  a  solution  of  iodide  of  potassium  (for  free 
chlorine). 

6th.  When  brought  to  the  boiling-point  with  a  concentrated 
solution  of  caustic  potash  it  should  not  become  colored.  (Ab- 
sence of  aldehyde  and  arsenic.) 

7th.  Sulphuric  acid  should  not  blacken  it  when  brought  in 
contact  with  chloroform. 

8th.  Mixed  with  concentrated  sulphuric  acid  and  shaken,  it 
should  separate  in  half  an  hour  into  two  colorless  layers. 

Chloroform  is  liable  to  sudden  changes,  and  exposure  to  light, 
an  imperfect  stopper,  or  partially  filled  bottle  frequently  affect 
its  purity ;  hence,  it  should  be  tested  before  using.     The  com- 


244  ARTIFICIAL    ANAESTHESIA. 

bined  action  of  permanganate  of  potash  and  a  caustic  alkali 
has  been  recommended  as  an  exceedingly  delicate  test  and  re- 
agent. 

Mode  of  Administering-  Chloroform. 

To  inhale  (inhalo)  is  to  inspire  or  draw  air,  either  alone  or 
charged  with  vapors  of  various  volatile  agents,  into  the  lungs. 

When  chloroform  was  first  discovered  as  an  anaesthetic  the 
apparatus  employed  was  that  designed  for  etherization,  but  of 
a  more  reduced  size.  It  was  found  that  the  less  volatile  nature 
of  chloroform  permitted  even  the  abandonment  of  all  compli- 
cated apparatus,  and  most  physicians  and  surgeons  preferred  to 
use  a  handkerchief  or  a  compress  of  linen  folded  to  several 
thicknesses  (some  even  preferring  to  have  it  starched  so  as  to 
retain  its  shape).  After  having  arranged  the  folds  (using  a 
safety-pin  to  hold  them  together)  in  a  cup  shape,  on  this  linen 
drop  several  drops  of  chloroform  from  a  graduated  bottle  (so  as 
to  be  able  to  measure  the  quantity  employed).  Apply  over  the 
mouth  and  nostrils  of  the  patient,  allowing  however  at  the 
beginning  enough  free  space  for  the  atmospheric  air  to  enter  with 
the  chloroform.  If  the  subject  be  nervous,  irritable  and  mani- 
fest a  feeling  of  sufi'ocation,  remove  the  compress  still  further, 
and  even  mix  a  small  portion  of  cologne  water  until  the  patient 
becomes  accustomed  to  the  odor. 

The  chief  objection  to  this  mode  of  employing  the  chloroform 
is  the  waste  and  the  tendency  of  the  moist  cloth  to  adhere  to 
the  parts  and  irritate  the  skin.  Eflforts  were  then  made  to 
overcome  or  diminish  these  objections  by  the  use  of  a  more 
complicated  apparatus. 

It  was  necessary  to  fulfil  two  requirements :  to  have  an  ab- 
sorbent surface  on  which  to  drop  the  chloroform,  and  to  permit 
the  access  of  air  which  must  be  mingled  with  the  anaesthetic 
vapors,  and  to  prevent  waste  of  the  chloroform. 

In  England,  where  chloroform  was  first  employed,  several 
apparatus  were  devised  by  "Snow,"  "  Sansom  &  Clover,"  etc. 
They  all  had  disadvantages  which  prevented  their  general 
adoption.    One  of  the  more  simple  inhalers  much  used  in  Eng- 


MODE    OF    ADMINISTERING    CHLOROFORM. 


245 


Plate  45. 


land  consisted  of  a  metallic  box,  with  the  margin  hollowed  out 
in  the  parts  which  correspond  to  the  nose  and  chin  of  the  pa- 
tient, and  of  which  the  bottom  and  lower  wall  are  pierced  by  a 
hole,  permitting  the  entrance  of  the  air. 

An  attachment  in  the  shape  of  a  horse-shoe,  fastened  to  the 
upper  wall  in  the  interior  of  the  apparatus,  permits  the  firm 
adjustment  of  several  rolls  of  linen,  or  two  bundles  of  lint,  on 
which  the  chloroform  is  dropped.  The  linen  or  lint  is  renewed 
each  time  the  box  is  used,  and  by  this  means  the  apparatus  is 
always  in  a  state  of  perfect  cleanliness. 

Then  they  had  "  Skinner's  "  apparatus,  a  mask  or  wire  frame 
over  which  was  attached  a  piece  of  woollen  stuff.  The  wire 
frame  is  placed  over  the  nose  and  mouth  of  the  patient,  and  on 
he  exterior,  or  the  woollen  cover,  is  dropped  a  certain  quantity 
of  chloroform. 

The  apparatus  of  Raynard  (of  Toulon),  Plate  45,  is  employed 
in  France,  especially  in  the  navj?-. 
It  is  composed  of  a  conical  horn 
of  pasteboard  (A),  pierced  by  a 
large  opening  at  the  top,  and  ter- 
minating in  a  mouth -piece  which 
fits  over  the  mouth  and  nose  of 
the  patient.  The  apparatus  is 
lined  on  the  inside  with  wool,  at 
a  certain  distance  from  the  top 
of  the  cone  is  a  diaphragm  (B), 
formed  by  several  folds  of  wool, 
presenting  in  the  centre  a  large 
aperture  for  the  entrance  of  at- 
mospheric air.  It  is  upon  this 
diaphragm  that  the  chloroform 
is  dropped  or  poured.  The  "an- 
aesthetic horn"  of  Raynard  has  the  disadvantage  of  leaving 
much  to  be  desired  in  the  way  of  cleanliness.  Patients  very 
often  expectorate  into  the  interior  of  the  apparatus  in  that 
stage  of  anaesthesia  which  the  French  call  "sputation,"  and  it 
is  difficult  to  cleanse  it  without  destroying  it. 


246 


ARTIFICIAL    ANAESTHESIA. 


At  Plate  46  is  seen  the  inhaler  which  is  made  by  Charriere, 
of  Paris.  It  is  a  wire  frame,  a,  B,  B  and  c,  on  which  is  fitted 
a  covering  of  muslin  which  is  held  in  place  by  wires  a  and  c. 
There  is  a  hook  at  the  top  which  is  held  by  the  left  hand,  while 
in  the  right  is  the  chloroform  in  a  graduated  bottle,  and  the 
chloroform  is  carefully  dropped  on  the  exterior  of  the  flannel, 
not  too  rapidly,  else  there  is  produced  a  choking  sensation.  In 
neither  of  these  inhalers  should  the  chloroform  be  poured,  else 
sudden  stoppage  of  the  respiration  and  suffocation  of  the  pa- 

Plate  46. 


Modification  Inhaler  of  Skinner  and  Charriere,  of  Paris. 


tient  take  place,  or  the  liquid  chloroform  may  pass  into  the 
larynx  and  cause  death. 

Clover's  apparatus,  which  we  have  described  in  its  original 
form  under  ether,  was  subsequently  modified  by  Dr.  Buxton. 

Junker's  apparatus  is  composed  of  a  bottle  having  two  tubes  ; 
it  is  enveloped  in  plated  steel,  but  this  envelope  is  pierced  by 
a  longitudinal  opening,  showing  what  is  inside  the  bottle  ;  this 
opening  has  marked  upon  it  a  graduated  scale,  which  designates 
the  quantity  of  the  anaesthetic  employed. 

A  hook  allows  the  operator  to  suspend  the  apparatus  from 
his  clothing.     One  tube  conveys  to  the  bottom  of  the  bottle  the 


MODE    OF    ADMINISTERING    CHLOROFORM.         247 

air,  which  is  forced  there  by  a  Richardson  bellows.  This  air, 
after  having  mingled  with  the  chloroform,  passes  out  by  an  at- 
tachment and  through  the  other  tube  to  the  mouth-piece,  which 
is  placed  before  the  mouth  and  nose  of  the  patient. 

This  mouth-piece,  of  hard  rubber,  has  a  valve  of  soft  rubber 
which  opens  with  expiration  and  closes  with  inspiration.  A 
movable  ring,  placed  at  the  point  where  the  vapors  arise,  and 
pierced  by  two  slits,  corresponding  to  two  openings  of  the  same 
calibre  in  the  attachment  which  prolongs  the  mouthpiece  on 
this  side,  allows  a  greater  or  less  quantity  of  pure  air  to  reach 
the  patient ;  this  being  mingled  with  the  anaesthetic  vapors,  is 
propelled  through  the  tube  into  the  mouth-piece. 

Half  an  ounce  of  chloroform  is  poured  into  the  bottle  through 
a  funnel-shaped  opening  fixed  in  a  screw  top ;  air  is  then 
pumped  through  the  chloroform,  and  in  its  passage  it  takes  up 
the  vapor.  The  foot  bellows  are  fixed  by  straps,  one  of  which 
slips  over  the  toe,  while  the  other  receives  the  heel  in  the 
longer  loop.  When  the  foot  presses  lightly,  the  air  in  the  bel- 
lows is  forced  through  the  tube  into  the  bottle,  thence  through 
the  other  tube  to  the  face-piece.  The  net-enclosed  ball  is  for 
equalizing  the  stream  of  air  and  the  avoidance  of  splashing. 
It  is  important  not  to  put  more  than  half  an  ounce  of  chloro- 
form into  the  bottle  at  once,  and  not  to  pump  the  air  spasmodi- 
cally or  too  forcibly  ;  otherwise  pure  chloroform  may  be  drawn 
through  the  system  of  tubes  into  the  face-piece.  Even  if  this 
should  not  happen,  a  strong  blast  of  chloroform -impregnated 
air  is  very  unpleasant  and  deleterious  if  allowed  to  impinge 
upon  the  face.  When  the  bottle  has  become  nearly  empty,  the 
mill-headed  stopper  which  closes  the -funnel  is  removed  and 
more  chloroform  is  added  ;  thus  the  apparatus  need  never  be 
unhooked  from  the  administrator's  coat  and  the  top  never  un- 
screwed until  the  administration  is  over,  when  the  bottle  should 
be  emptied  and  cleaned. 

Dr.  Buxton  remarks:  "A  practical  acquaintance  with  the 
imperfections  of  this  inhaler  has  led  to  modifications  of  value, 
though  it  must  not  be  supposed  that  by  its  use  the  patient  is 
placed  outside  the  range  of  possible  danger." 


248  AKTIFICIAL    ANESTHESIA. 

The  Scotch  Method  of  Adiniiiistering-  Chloroform,^ 

In  July,  1892,  the  author  was  invited  as  one  of  the  Commit- 
tee on  Anaesthetics  of  the  British  Medical  Association,  prior 
to  the  meeting  at  Nottingham,  to  be  present  at  the  clinics  of 
Prof.  Chiene  and  witness  his  method  of  administration  of 
chloroform. 

The  following  are  his  teachings  in  his  syllabus  of  Lectures  on 
Surgery — Chloroform  : 

A.  Action  of  chloroform  is  (first)  stimulant ;  (second)  seda- 

tive. 

(a)  Abolishes  sensation. 

(b)  Abolishes  power  of  motion  and  reflex  action. 

(c)  Stops  respiration. 

(d)  Stops  hearts  action, 

(e)  Kills  patient. 

B.  Method  of  Administration — Towel  versus  Engine — Brains 

versus  Valves. 

1.  Give  all  your  attention. 

2.  Have  your  artery  forceps  ready. 

3.  Watch  the  breathing. 

4.  Watch  patient's  appearance. 

How  do  you  know  when  the  patient  has  had  enough  ? 

(a)  Insensibility  of  conjunctiva. 

(b)  Muscular  relaxation. 

(c)  Local  insensibility  of  part  to  be  operated  on. 

C.  Dangers. 

(a)  Tongue  falling  back. 

(b)  Glottis  closing. 

(c)  Fainting. 

(d)  Vomiting. 

(e)  Respiration  and  heart's  action  stopped. 

D.  Signs  and  treatment  of  these  dangers. 

(a)  Use  the  artery  forceps  to  draw  the  tongue  forward. 

(b)  Lower  the  head,  dash  cold  water  on  the  face  and 

chest,  open  windows  and  doors. 

*  Prof.  Jolin  Chiene,  University  of  Edinburgh,  Scotland. 


SCOTCH  METHOD  OF  ADMINISTERING  CHLOROFORM.      249 

(c)  Small  doses  of  solution  of  cocaine,  mustard  plaster 

to  the  epigastrium,  with  lime-water  and  milk  ;  ice 
in  small  pieces. 

(d)  Artificial  respiration  ;  elevate  the  upper  part  of  the 

body.* 

Drs.  Wallace,  Musselman,  and  his  chief  assistant,  Dr.  Emer- 
son, all  ready  to  assist  or  answer  any  questions.  Number  of 
students  and  medical  men  in  attendance  from  25  to  30.  The 
chloroform  was  given  to  the  care  of  one  medical  man,  who  had 
been  at  least  one  month  under  careful  instruction  in  its  use. 
The  professor  stated  that  the  latter  was  simply  to  attend  to  that 
duty  and  nothing  else;  he  was  not  even  to  restrain  the  patient. 
We  noticed  he  had  a  woman  as  an  assistant  who,  in  the  first 
case,  attended  to  the  pulse.  We  found  that  the  operator 
watched  the  patient,  so  as  to  be  sure  everything  was  going  on 
all  right,  as  he  considered  this  all  important  when  performing 
the  most  difficult  operation.  He  stated  that,  as  a  rule,  it  was 
most  important  only  to  watch  the  respiration.  He  also  stated 
that  there  was  no  preparation  of  the  patient  (this  was  incor- 
rectly reported  in  the  British  Med.  Joimi.),  only  the  giving  of 
a  cup  of  beef-tea  at  8  a.m.  No  special  examination  of  the 
habits  of  the  patient,  his  heart,  lungs  or  kidneys.  The  chloro- 
form was  administered  on  a  towel. 

He  performed  four  operations,  none  of  them  capital  ones. 
Three  of  the  cases  did  well  under  the  chloroform,  but  in  the 
fourth,  for  removal  of  anterior  and  posterior  tibial  nerve  for 
pain  in  stump,  the  patient,  who  was  a  sailor,  resisted  the  ac- 
tion of  the  chloroform,  and  it  had  to  be  removed  twice,  as  he 
had  an  epileptiform  convulsion  with  rigid  chest,  so  that  the 
younger  assistants  became  alarmed,  but  not  the  Professor,  who 
inquired  of  us  what  we  did  in  such  cases.  We  stated  that  we 
withdrew  the  chloroform  entirely  or  gave  ether.  Ultimately  he 
was  able  to  perform  the  operation  with  considerable  difficulty, 
as  the  man  struggled  violently,  and  required  several  assistants 
to  control  him.    Prof.  Chiene  stated  that  such  cases  were  termed 

*  Clinic  of  Professor  John  Chiene,  University  of  Edinburgh,  July 
11,  1893. 

17 


250  ARTIFICIAL    ANESTHESIA. 

by  him  alcoholists,  sailors,  as  a  rule,  being  verj^  intemperate 
men.  Such  cases  die  in  the  hands  of  an  ordinary  practitioner 
who  attempts  to  give  chloroform  alone  without  the  required 
number  of  assistants  (see  case  reported  in  Philadelphia  Med. 
News,  September  24,  1893). 

The  conclusion  arrived  at  by  the  Hyderabad  Commission  on 
Anaesthetics,  that  chloroform  kills  by  interference  with  respira- 
tion, is,  no  doubt,  correct  in  the  large  majority  of  fatalities  with 
this  drug.  When  the  commission^  however,  goes  on  to  lay  it 
down  as  a  law  in  the  administration  of  chloroform  that  the 
pulse  need  not  be  noted ;  that,  indeed,  noting  it  is  actually 
harmful  because  it  takes  the  anaesthetist's  attention  off  the  only 
thing  worth  watching,  i.e.,  the  respiration,  it  goes  too  far.  A 
large  number  of  cases  have  of  course  been  published  in  which 
chloroform,  properly  administered,  has  caused  death  by  paralyz- 
ing the  heart  before  it  interfered  with  the  process  of  respira- 
tion ;  but  the  teaching  of  the  commission  is  so  positive,  and  as 
many  surgeons  and  anaesthetists  think  so  dangerous,  that 
all  cases  in  which  the  heart  was  first  affected  should  be  made 
known. 

Two  such  cases  occurred  at  the  Royal  Victoria  Hospital, 
Netley,  lately  {London  Lancet,  March  18,  1893).  A  skilled 
anaesthetist  gave  the  chloroform  from  a  "  Krohne's"  inhaler, 
than  which  there  is  no  better  apparatus  for  the  purpose,  and  no 
struggling  took  place  in  either  case.  One  was  the  case  of  a  child 
aged  three  years,  on  whom  the  operation  of  needling  was  being 
performed  for  a  congenital  cataract ;  but  as  the  operation  was 
completed,  the  boy's  face  suddenly  became  pale,  and  the  pulse 
was  found  to  be  imperceptible  at  the  wrist  and  artery  in  the 
neck.  At  this  time  no  cessation  of  the  movements  of  the  chest 
and  abdominal  walls  took  place,  and  air  was  heard  to  pass  in 
and  out  of  the  lungs  freely.  Under  the  use  of  the  interrupted 
current,  friction  and  ether  subcutaneously,  the  attack  of  syn- 
cope passed  off.  The  second  case  was  that  of  a  man  on  whom 
the  radical  cure  was  being  performed  for  an  inguinal  hernia. 
The  patient  took  the  chloroform  freely  until  the  sack  of  the 
hernia  was  twisted.  When  this  was  done,  the  man's  face  im- 
mediately blanched  and  the  pulse  became  imperceptible,  whilst 


CHLOROFORM.  251 

the  movements  of  respiration  continued  vigorous  and  effective. 
Ether  was  injected,  the  head  lowered,  sponges  wrung  out  of 
very  hot  water  were  applied  over  the  heart  and  electricity  to  the 
neck.  In  about  five  minutes  the  pulse  was  again  felt,  and  the 
man  recovered.  Had  the  rules  laid  down  by  the  Hyderabad 
Commission  for  the  administration  of  chloroform  been  carried 
out  in  these  two  cases  ;  had  the  indications  afforded  by  the  ob- 
servation of  the  pulse  been  disregarded,  and  the  condition  of 
the  respiration  alone  noted,  the  chances  are  that  the  deaths  of 
these  patients  would  have  had  to  be  added  to  the  already  too 
long  list  of  "  deaths  under  chloroform." 

Facts  collected  from  the  published  statements  of  "  The  Lan- 
cet's Commission  on  Anaesthetics,"  March  15  and  April  15, 
1893,  were  to  supplement  the  work  of  the  second  "Hyderabad 
Commission,  who  made  all  of  its  experiments  on  living  animals." 
This  last  commission  of  the  Lancet  was  a  consideration  of  the  re- 
sults arrived  at  by  clinical  observations  from  all  the  larger  hospi- 
tals of  the  Continent,  as  well  as  India,  America  and  the  Colonies. 

Dr.  Dudley  Buxton  gave  the  directions  to  the  inquiry  without 
any  reference  to  his  own  views,  in  order  to  arrive  at  a  con- 
tinuous series  of  cases  from  1847  (the  date  of  the  first  employ- 
ment of  chloroform  as  an  anaesthetic).  Not  only  were  the  above 
sources  of  information  used,  but  the  records  of  Snow  (1858)  and 
those  collected  by  the  committee  of  the  Royal  Medical  and 
Chirurgical  Society,  published  in  their  transactions  in  1864. 
(The  report  deals  with  all  the  anaesthetics,  but  chiefly  chloro- 
form.) 

Classification  of  Cases. 

The  reports  of  the  cases  have  been  divided  into  the  following 
classes  :  (1)  Deaths  under  and  apparently  due  to  an  anaesthetic ; 
(2)  Deaths  under  and  remotely  due  to  an  anaesthetic;  and  (3) 
untoward  cases,  7.e.,  cases  in  which  some  mishap  occurred  which 
was  not  followed  by  fatal  results,  but  which  was  directly  or  re- 
motely due  to  the  anesthetics  employed. 

Cliloroforin. 

No  age  possesses  immunity  from  death  from  anesthetics. 
The  greatest  number  of  deaths  in  males  appears  to  take  place 


252  ARTIFICIAL    ANESTHESIA. 

between  the  ages  of  twenty-five  and  fifty.  The  fatalities  of 
women  are  most  frequent  between  the  ages  of  twenty-one  and 
forty-five. 

GrEOGRAPHicAL  DISTRIBUTIONS  OF  FATALITIES. — Deaths  are 
reported  from  all  quarters  of  the  globe.  It  was  noticed  that  in 
Scotland,  where  chloroform  is  so  widely  and  extensively  em- 
ployed, few  reliable  sources  of  information  exist  of  the  deaths 
which  result  from  its  exhibition. 

Deaths  do  occur  from  chloroform  in  Scotland,  notwithstand- 
ing a  contrary  belief  has  been  assiduously  promulgated.  Such 
cases  are  not,  however,  often  brought  to  light,  since  Coroners' 
inquests  are  almost  unknown,  and  there  is  not  the  opportunity 
for  newspaper  publicity  that  occurs  in  England  and  America. 
A  casual  search  of  medical  journals  reveals  the  following  chlo- 
roform casualties  :  Edinburgh  Royal  Infirmary  (1878  to  1880), 
3  deaths ;  Western  Infirmary,  Glasgow  (1883  to  1886),  3  deaths ; 
Royal  Infirmary,  Glasgow  (1883  to  1885),  2  deaths;  other  parts 
of  Scotland  (1881  to  1883),  6  deaths.  England,  110  deaths  to 
14  in  Scotland  during  the  same  period.  Population  of  England 
in  1880,  28,247,151  ;  Scotland,  3,991,490.  Ratio  of  deaths  in 
England,  1  to  256,792  ;  in  Scotland,  1  to  approximately  285,107; 
vide  Dr.  Alex.  Wilson. 

Methods  Employed  for  Administering-  Chloroform* 

1.  Those  in  which  no  special  form  of  inhaler  was  employed  : 

Chloroform  poured  on  a  handkerchief, 

Chloroform  poured  on  a  towel. 

Chloroform  poured  on  a  napkin, 

Chloroform  poured  on  a  sponge, 

Chloroform  poured  on  lint, 

Chloroform  poured  into  an  extemporized  cone. 
In  fewer  instances  the  process  is  described  as  having  been 
conducted  by  the  "open  method,"  or  chloroform  given  from  a 
"cone  of  paper,"  "cloth,"  "compress"  and  so  on.  The  re- 
corded deaths  resulting  from  chloroform  being  administered 
without  an  inhaler  are  rather  more  than  double  those  occurring 
when  an  inhaler  is  used. 


CAUSES    ASSIGNED    FOR    DEATH.  253 

2.  Deaths  under  chloroform  when  a  specified  apparatus  (in- 
haler) was  emploj^ed :  the  order  of  deaths  during  their  use. 
The  following  are  the  methods  employed  : 

Inhalers  (kind  unspecified). 

Skinner's  inhaler  (flannel  mask  stretched  on  a  wire  frame). 

Snow's  inhaler. 

Junker's  inhaler. 

Clover's  inhaler. 

Esmarch's  inhaler. 

Metallic  inhaler. 

Grey's  Hospital  inhaler. 

Morton's  ether  inhaler. 

Weiss' s  apparatus. 

Open  method,  chloroform  "  poured  "  on  lint  after  the  man- 
ner of  "Syme."  who  taught  that  plenty  of  the  drug 
should  be  used. 

Open  method,  chloroform  "dropped"  on  lint  after  the 
manner  advocated  by  the  dosmetric  school,  who  teach  that 
by  dropping  on  lint  almost  safety  is  insured. 

Causes  Assigned  for  Death. 

Of  predisposing  causes  intemperance  and  wasting  disease,  the 
existence  of  emphysema,  pathological  conditions  of  the  heart 
and  bloodvessels  are  the  most  noted.  ■■ 

Immediate  Causes  of  Death — Heart  Failure  and  Re- 
spiratory Cessation.  —Of  the  506  cases  recorded  and  which 
have  come  under  the  "Lancet  Commission  "  the  pulse  is  stated 
by  the  person  who  reports  the  death  to  have  failed  in  first  143 
instances,  while  in  59  records  the  respiration  is  described  as 
being  primarily  stopped  ;  in  46  it  is  mentioned  that  the  respira- 
tion and  circulation  (as  judged  by  the  pulse)  ceased  simultane- 
ously; whilst  in  36  the  pulse  probably,  it  is  asserted,  failed 
first,  in  4  the  respiration  probably  failed  first,  and  in  12  they 
probably  failed  simultaneously;  in  211  cases  no  record  was 
given  as  to  which  failed  first. 

Of  the  cases  collected  by  the  committee  of  the  Royal  Medi- 
cal and  Chirurgical  Society,  out  of  83  cases,  26  are  given  in 
which  the  pulse  failed  first,  4  in  which  respiration  failed  first, 


254  ARTIFICIAL    ANAESTHESIA. 

11  in  which  respiration  and  circulation  failed  simultaneously,  9 
in  which  the  pulse,  probably,  failed  first,  2  in  which  the  respi- 
ration, probably,  failed  first,  and  7  in  which  they,  probably, 
failed  simultaneously,  while  24  cases  had  no  records  of  these 
points. 

A  very  careful  consideration  of  all  the  records  which  have 
been  brought  under  the  notice  of  the  commission  would  seem 
to  favor  the  conclusion  that  in  the  lar^e  majority  of  cases,  the 
symptoms  and  phenomena  detailed  bear  out  the  view  that 
death  was  due  to  syncope  in  so  far  as  the  clinical  evidence  would 
decide^  one  way  or  the  other. 

In  drawing  up  this  summary  the  greatest  difficulty  has  arisen 
in  many  cases  from  the  looseness  and  inadequacy  of  the  pub- 
lished records.  It  has  been  necessary  in  some  instances  to  place 
apparently  similar  cases  under  different  headings,  when  the 
causes  assigned  for  death  have  been  diiferent,  although  the 
lessons  have  been  similar.  Thus  in  one  case  death  is  attributed 
by  the  narrator  to  syncope,  although  it  is  stated  that  food  was 
found  in  the  wind-pipe,  which,  it  may  be  presumed,  caused 
respiratory  trouble,  leading,  it  may  be,  to  syncope  as  an  ulti- 
mate result. 

No  attempt  has  been  made  to  tabulate  information  as  to  the 
quantity  of  chloroform  used  or  its  quality. 

Repeated  Inhalation. 

Of  the  cases  examined  11  males  who  had  died  under  chloro- 
form had  taken  it  safely  once  before,  11  females  and  13  males 
more  than  once. 

Purified  Chloroform — Anaesthetic  and  Physiolog-ical 

Action. 

When  one  per  cent,  of  chloroform  is  mixed  with  three  to  five 
per  cent,  of  atmospheric  air,  it  becomes  charged  with  it,  and  in 
this  form  it  is  usually  employed  as  an  anaesthetic. 

The  amount  of  vapor  which  can  be  taken  up  (held  in  solution) 
by  the  air  of  the  atmosphere,  varies  with  the  elastic  tension  of 
the  chloroform  vapor  at  different  temperatures.  Thus,  at  40° 
R,  a  small  quantity  of  chloroform  would  evaporate  into  air  ;  at 


PURIFIED    CHLOROFORM. 


255 


130°  F.,  so  much  would  volatilize  as  to  give  rise  to  an  almost 
pure  chloroform  vapor.  In  the  following  table,  taken  from 
Snow's  "Anaesthetics,"  the  amount  of  chloroform  in  vapor  is 
shown  in  100  cubic  inches  of  saturated  mixture  of  air  and 
chloroform  at  different  temperatures  : 


jgrees 
F. 
40 

Air 
per  cent. 
94   . 

Vapor 

per  cent 
6 

45  . 

.   93   . 

•     > 

7 

50 

92   . 

8 

55 

90   . 

.   10 

60 

88   . 

.   12 

65 

85   . 

15 

70 

81   . 

.   19 

75 

78  . 

22 

80 

74  . 

.   26 

85 

70   . 

30 

90 

£>  _i  1 

£> 

65   . 

1 

n 

35 

One  grain  of  chloroform  in  100  cubic  inches  of  air  produces 
the  second  degree  of  narcosis,  but  never  carries  chloroformiza- 
tion  further.  This  corresponds  to  a  proportion  of  1  part  by 
measure  of  chloroform  in  16,285  parts  blood,  or  0.0000614,  the 
proportion  by  weight.  Two  grains  in  each  100  cubic  inches  of 
air,  or  2V  saturation  (uniiy  being  saturation),  produces  the 
fourth  stage  of  narcosis,  or  0.0001228  the  proportion  by  weight. 

Any  proportion  above  two  grains  in  the  hundred  causes  in- 
terference with  respiration  ;  three  grains  in  the  hundred  seems 
about  the  ratio  which  renders  respiration  impossible.  Three 
grains  represent  2.3  cubic  inches  vapor,  and  as  air  ,at  100°  F. 
can  take  up  43.3  per  cent,  of  its  volume,  the  blood  must  contain 
from  -^  to  xV  of  the  proportion  it  is  capable  of  absorbing  when 
the  respiratory  centres  are  poisoned. 

Snow  found  further,  that  calcuhiting  the  weight  of  the  blood 
as  thirty  pounds,  twelve  minims  of  chloroform  in  the  circulation 
produce  narcosis  of  the  second  degree ;  eighteen  minims,  the 
third  degree  (surgical  anaesthesia) ;  twenty-four  deep  narcosis 
(fourth  stage),  and  thirty-six  should  paralyze  the  medullary 
centres.     In  practice  more  is  needed,  because  a  certain  propor- 


266  ARTIFICIAL    ANAESTHESIA. 

tion  evaporates  from  the  tracheal  and  bronchial  surfaces,  and 
is  carried  out  in  expiration.  If  twelve  minims  be  evaporated 
into  a  bladder,  and  inhaled  to  and  fro,  no  more  air  being 
allowed  than  can  be  blown  from  the  lungs,  narcosis  of  the  sec- 
ond degree  actually  results.  Now,  taking  thirty-six  minims  as 
a  lethal  dose,  the  following  considerations,  upon  which  Snow 
strongly  insisted,  explain  how  easily  this  quantity  may  enter 
the  circulation  if  the  administrator  be  not  perpetually  upon  his 
guard  against  over  dosage ;  eighteen  minims  represent  the 
amount  absorbed  to  produce  surgical  narcosis ;  this  amount 
might  be  absorbed  by  the  use  of  thirty-six  minims,  the  remain- 
ing eighteen  minims  being  exhaled  as  above  mentioned.  These 
thirty-six  minims  represent  37.5  cubic  inches  of  vapor,  which, 
at  60°  F. ,  would  require  257  cubic  inches  of  air.  The  300  cubic 
inches  thus  formed  would  be  inspired  in  twelve  respiratory  acts 
(25  cubic  inches  being  the  amount  of  tidal  air).  Now,  if  a 
vapor  of  this  strength  were  continuously  inhaled,  the  residual 
and  complemental  air  would  become  saturated,  and  as  about 
250  cubic  inches  represent  the  air  in  the  lungs,  this  amount 
would  at  60°  F.  contain  the  vapor  of  thirty  minims.  Assuming 
only  half  this  quantity  to  be  absorbed,  that  is  fifteen  minims, 
we  should  then  have  18  +  15,  or  thirty-three  minims  in  the 
blood,  an  amount  almost,  if  not  quite,  enough  to  paralyze  the 
respiratory  centre.  These  points  being  held  in  remembrance 
will  explain  many  cases  of  chloroform  death  ascribed  to  "idio- 
syncrasy," or  the  "  fatty  heart, "  which  stand  inexpert  chloro- 
formists  in  such  good  stead.  Death  from  chloroform  does  not, 
however,  always  result  from  respiratory  paralysis. 

Death  occurs  from  heart-failure,  cardiac  syncope  or  asphyxia, 
from  too  large  a  quantity  of  chloroform  being  employed ;  also , 
owing  to  the  closure  of  the  glottis,  or  paralysis  of  laryngeal 
muscles  ;  also,  respiratory  failure,  or  absorption  into  the  blood 
and  nerve  structures,  producing  entire  alteration  of  them. 

What  has  experimentation  determined  definitely  in  regard  to 
the  action  of  chloroform?  The  action  of  chloroform  on  the 
brain  is,  first,  congestion  ;  but  when  there  is  complete  anaes- 
thesia, it  produces  decided  anaemia  in  man  and  animals.  The 
muscular  excitement  of  the  second  stage  is,  according  to  experi- 


PURIFIED    CHLOROFORM.  257 

ments,  purely  physical ;  and  there  is,  during  the  production  of 
anaesthesia,  a  steady  lowering  of  reflex  action. 

Chloroform  at  first  induces  contraction,  and  afterwards  much 
the  same  pupillary  phenomena  are  seen  during  the  action  of 
drugs  which  affect  the  cerebro-spinal  system,  even  in  those, 
which,  in  the  first  instance,  produce  myosis.  In  such,  if  the 
action  of  the  drug  be  pushed,  a  stage  is  arrived  at  when  the 
function  of  the  respiratory  and  cardiac  centres  is  so  seriously 
compromised  that  the  pupils  become  widely  dilated  and  fixed. 
This  may  be  illustrated  by  the  action  of  three  drugs — opium, 
chloroform  and  alcohol.  In  opium  coma,  the  pupil  is  always 
firmly  contracted,  while  in  alcohol  coma,  we  can  distinguish  it 
from  opium,  if  we  pull  the  beard  or  hair,  as  this  act  will  cause 
temporary  dilatation. 

In  chloroform  narcosis,  the  same  pupillary  phenomena  are 
observed  during  the  extreme  stages.  From  personal  observa- 
tions, extending  over  several  hundred  carefully  recorded  cases, 
it  is  seen  that  the  pupils  are  in  a  very  variable  state  during  the 
preliminary  periods,  much  too  variable  to  permit  any  rule  being 
formulated  regarding  them.  When,  however,  reflex  action  is 
abolished,  except  in  the  cardiac  and  respiratory  centres,  the 
pupils  become  contracted  and  fixed.  (Dr.  MacEwen,  of  Grlas- 
gow,  stated  to  us,  that  young  operators  frequently  make  the 
serious  mistake  of  judging  that  the  patient  is  ready  for  an 
operation  merely  from  the  test  of  touching  the  cornea  with 
impunity,  when  an  examination  of  the  opposite  eye  will  con- 
vince him  that  he  has  produced  by  the  close  application  of  the 
chloroform  of  the  cloth,  nothing  more  than  a  local  anaesthesia, 
confined  to  one  eye.) 

Anaesthesia  from  chloroform  is  divided  into  five  stages,  as 
follows  : 

In  the  first  stage — from  commencement  of  inhalation  to  im- 
pairment of  consciousness — fulness  of  the  head,  ringing,  buzz- 
ing in  the  ear,  palpitation  of  the  heart  are  sometimes  felt  ; 
there  is  also  some  diminution  of  common  sensation. 

In  the  second  stage  the  mental  powers  are  impaired,  although 
not  suspended.  The  patient  remains  passive,  as  if  sleeping,  or 
occasionally  makes  a  voluntary  movement.     Sometimes  laugh- 


258  ARTIFICIAL    ANESTHESIA. 

ing,  singing,  talking  are  indulged  in  during  this  stage.  Snow 
believed  that  dreaming  occurs  at  this  time,  and  then  only. 
Towards  the  close  the  patient  becomes  restive  ;  he  attempts  to 
remove  the  face-piece  or  towel,  for  he  is  conscious  of  being  in- 
convenienced by  the  vapor,  but  not  of  the  necessity  for  remain- 
ing passive.  Common  sensation  is  much  blunted,  so  that 
patients  submit  without  expostulation  to  painful  manipulation. 
This  degree  of  narcotism  is  sufficient  for  obstetric  practice  and 
the  after-stage  of  prolonged  operations.  As  a  rule,  struggles 
or  expressions  of  pain  which  show  themselves  at  the  time  are 
not  subsequently  remembered. 

hi  the  third  stage  all  voluntary  movements  are  lost.  The 
conjunctival  vessels  become  full,  the  muscles  rigid,  and  struggles, 
even  epileptiform  convulsions,  may  supervene.  As  the  stage 
advances  the  muscles  relax."  Inarticulate  jabbering  and  mouth- 
ing occur.  Although  really  insensitive  to  pain,  the  patient 
may  flinch  or  even  cry  out.  Later  in  this  stage,  all  reflex  acts 
are  abolished,  the  conjunctival  and  nasal  receding  last.  The 
patella  jerk  also  persists  late,  while  under  deep  anaesthesia  the 
ankle-joint  phenomenon  appears. 

In  the  fourth  stage  breathing  is  stertorous,  the  pupils  dilated, 
and  the  muscles  completely  relaxed  and  flaccid.  In  this  stage 
the  patient  is  profourtdly  unconscious,  and  is  drifting  into  dan- 
ger. Such  deep  narcosis  is  seldom  needed,  save  for  the  reduc- 
tion of  old-standing  dislocations,  etc. 

The  fifth  stage  is  the  interval  which,  following  the  fourth 
degree  of  narcosis,  intervenes  between  the  respiratory  embar- 
rassment and  total  cessation  of  breathing.  Even  after  dyspnoea 
has  passed  into  apnoea,  the  heart  continues  to  beat  for  a  brief 
while.  This  stage  marks  the  period  when  chloroform  tension 
in  the  blood  is  great  enough  to  paralyze  the  respiratory  centres 
in  the  medulla  oblongata. 

The  third  stage  may  be  regarded  as  the  safety  zone  of  com- 
plete chloroform  narcosis.  But  if  anaesthesia  be  pushed  beyond 
this  stage,  wide  dilatation  of  the  pupils  ensues,  indicating  a  sus- 
pension of  function  in  the  cardiac  and  respiratory  centres. 
This  is  a  most  critical  condition,  though  one  by  no  means  neces- 
sarily fatal,  as  by  lowering  the  head  and  raising  the  floor  of  the 


THE  PUPIL  AS  A   GUIDE  IN   GIVING   CHLOROFORM.       259 

table,  and  by  promptly  carrying  out  artificial  respiration,  even 
while  feeble  respiratory  eiForts  are  being  made  by  the  patient, 
the  danger  may  be,  and  frequently  has  been,  averted.  Given 
a  person  free  from  organic  lesion  of  the  nerve  centres,  heart  or 
lungs,  in  whom,  during  chloroform  narcosis,  stable  mydriasis 
suddenly  occurs  as  a  result  of  the  action  of  chloroform  on  the 
respiratory  centres,  the  patient  ought  to  recover  if  artificial 
respiration,  coupled  with  the  lowering  of  the  head,  be  promptly 
resorted  to,  and  the  former  efficiently  carried  out.  It  is  inter- 
esting to  note,  in  such  cases,  the  marked  efiect  produced  by  ele- 
vating the  foot  of  the  table,  so  as  suddenly  to  place  the  patient's 
head  and  thorax  at  a  very  low  level,  the  pupils  becoming 
quickly  contracted.  In  this  connection,  however,  it  ought  to  be 
borne  in  mind  that  one  of  the  earliest  indications  of  a  return 
of  reflex  action  is  vomiting,  which,  as  a  rule,  is  accompanied  by 
dilated  pupils,  the  result  of  cerebral  ansemia. 

In  cases  where  the  functions  of  the  cerebro- spinal  system, 
especially  of  the  cardiac  and  respiratory  centres,  have  already 
been  enfeebled  (by  organic  lesion  or  otherwise),  chloroform 
acts  more  powerfully,  a  few  whififs  sufficing  to  induce  complete 
insensibilitj",  and  the  administration  of  an  ordinary  dose  giving 
rise  to  an  alarming  state,  which  only  prompt  measures  can 
prevent  from  becoming  fatal.  In  such  cases  the  pupils  very 
readily  pass  into  wide  dilatation,  with  a  very  small  amount  of 
chloroform. 

When  the  function  of  the  brain  is  suspended  by  want  of 
oxygenated  blood,  the  pupils  are  widely  dilated  and  fixed. 

This  may  be  seen  in  cases  of  asphyxia,  either  by  poisonous 
gases  or  arising  from  mechanical  causes.  It  was  once  observed 
by  Dr.  MacEwen  in  two  men,  who  had  all  but  succumbed  by 
inhaling  coal-gas,  emanating  from  a  broken  gas-pipe  in  their 
bed-room,  and  it  is  also  seen  in  cases  of  hanging. 

The  Pupil  as  a  Gviide  in  Giving-  Cliloroforni. 

Neilson  considers  the  pupil  a  reliable  indication  of  a  patient's 
condition,  under  chloroform  anaesthesia,  and  concludes  from  hig 
experiments  as  follows : 

"1.  The  effect  produced  by  chloroform  on  the  pupil  is,  at  first, 


260  ARTIFICIAL    ANESTHESIA. 

dilatation,  varying  in  degree  and  duration,  then  contraction  as 
the  narcosis  becomes  profound,  and  dilatation  again  when  the 
sensibilitj'  is  returning.  If  the  administration  be  still  con- 
tinued, with  the  pupil  strongl}^  contracted  and  motionless,  the 
pupil  will  also  dilate,  but  in  this  case  more  suddenly  and  com- 
pletely, and  will  be  coincident  with  a  state  from  which  it  will 
be  difficult  or  impossible  to  resuscitate  the  patient.  This  latter 
is  the  dilatation  of  asphyxia. 

"2.  So  long  as  the  pupil  dilates  in  response  to  excitation  by 
pinching,  etc. ,  the  patient  is  not  sufficiently  narcotized  for  the 
operation  to  be  proceeded  with  unless  the  latter  is  slight  and 
does  not  require  complete  anaesthesia. 

' '  3.  When  the  pupil  becomes  strongly  contracted  and  immobile, 
no  more  chloroform  should  be  given  until  it  begins  to  dilate 
again.  If,  then,  further  anaesthesia  be  required,  a  little  more 
chloroform  should  be  given  until  the  pupil  again  contracts. 

' '  4.  The  occurrence  of  sickness  causes  dilatation  similar  to,  but 
more  sudden  than,  that  which  happens  when  sensibility  is  re- 
turning, and  the  efforts  of  vomiting  have  the  effect  of  arousing 
the  patient." 

During  the  first  half-minute  of  the  inhalation  of  chloroform, 
there  is  a  progressive  lowering  of  the  arterial  pressure.  Chloro- 
form, if  injected  into  the  jugular  vein,  instantly  arrests  the 
heart's  action. 

Chloroform  produces  contraction  of  the  red  blood  disks ;  if, 
however,  air  be  admitted  to  blood  containing  chloroform,  the 
red  corpuscles  rapidly  disappear,  dissolving  in  the  serum,  out 
of  which,  after  a  time,  haematin  crystallizes.  One  authority 
states  that  after  anaesthesia  bile-acids  appear  in  the  blood ; 
and  it  has  been  found  that  the  oxygen  of  the  blood  undergoes 
an  increase  during  anaesthesia.  During  the  action  of  chloroform 
the  temperature  falls,  the  circulation  is  retarded,  and  the  skin 
gives  off  less  insensible  perspiration. 

According  to  the  recent  experiments  of  Ranke,  which  we 
have  before  referred  to  and  repeated  on  several  small  animals 
(and  this  is  also  the  view  of  the  late  Claude  Bernard),  the 
nature  of  the  action  of  chloroform  upon  the  nerve  cells  is  slight 
coagulation  ;  but  if  the  animal  was  killed  with  the  chloroform, 


TOXICOLOGICAL    EFFECTS.  261 

there  was  hardening  of  the  nerve  trunks  and  entire  change,  in 
which  evident  coagulation  of  the  albuminoid  tissues  took  place. 
If  chloroform  was  mixed  with  blood  not  exposed  to  the  air, 
there  is  no  change  except  contraction,  either  shown  under  the 
microscope  or  by  spectrum  analj'sis ;  this  we  have  repeatedly 
determined  in  the  frog,  rabbit,  pigeon,  etc. 

Toxicological  Effects. 

Chloroform  is  the  most  potent  and  agreeable  anaesthetic,  but 
the  most  dangerous,  and  is  the  one  in  which  death  may  occur 
at  any  and  every  stage  by  inhalation.  Chloroform  kills  so  sud- 
denly that  neither  skill  nor  care  can  always  guard  against  a 
fatal  result.  Another  disadvantage  of  chloroform  is  its  high 
boiling-point,  requiring  a  great  amount  of  heat  and  vital  force 
to  exterminate  it  from  the  body,  so  that  it  is  probably  never 
eliminated  entirely  by  the  lungs,  but  only  with  the  aid  of  all 
excreting  organs.  Any  deficiency  or  derangement  of  the  body 
which  may  consequently  lead  to  such  suppression  or  elimination, 
causes  the  nervous  system  to  be  overwhelmed  with  consequent 
inactivity.  Almost  all  anaesthetics  may  kill  during  the  first 
stage  by  asphyxia  ;  the  air  may  be  very  highly  charged — even 
saturated — with  the  agents ;  so  much  so,  that  owing  to  its  pun- 
gency it  cannot  be  breathed,  and  if  forced  upon  the  patient, 
stifles  and  suffocates  him  in  exactly  the  same  manner  as  would 
sulphur  burned  under  his  nostrils ;  death  would  thus  occur 
without  much  having  entered  the  body. 

Owing  to  the  danger  which  accompanies  its  use,  chloroform 
should  onlj^  be  administered  when  other  anaesthetics  are  not 
available  ;  or  under  the  especial  circumstance  that  without  it 
the  shock  of  the  operation  might  kill  the  patient.  In  railroad 
accidents,  and  military  surgery,  it  becomes  at  times  absolutely 
necessary  ;  and  in  the  holds  of  ships,  especially  those  of  iron, 
where  the  temperature  is  very  high,  it  is  resorted  to  on  account 
of  its  rapidity  of  action,  smallness  of  quantity  required,  cheap- 
ness, small  bulk  in  transportation,  and  the  less  risk  of  explo- 
sion and  ignition.  In  obstetrics,  chloroform  is  used  with  com- 
parative safety  to  the  mother,  although  a  few  deaths  have  been 
reported ;   but    from    our    observations    taken,    in    carefully- 


262  ARTIFICIAL    ANESTHESIA. 

watched  cases,  it  is  apt  to  be  fatal  to  the  infant.  Conclusions 
have  been  drawn,  that  in  long  and  instrumental  labors,  ether, 
or  bromide  of  ethj^l,  although  not  so  pleasant,  are  much  safer 
to  the  child. 

The  s\'mptoms  which  usually  occur  as  precursors  of  death 
from  chloroform  are  a  sudden  paleness  or  lividity  of  the  coun- 
tenance, shallow  breathing,  stertor,  loss  of,  or  a  quick  and  weak 
pulse,  tossing  about  of  the  patient,  delirium,  convulsions,  or 
coma. 

Chloroform  should  never  be  administered  in  a  sitting  posture, 
nor  should  a  patient  rise  suddenly  when  under  its  influence. 

JVliat  is  the  chief  danger  to  be  apprehended  when  chloroform 
has  been  used,  and  how  do  we  prevent  fatal  symptoms,  as 
closure  of  the  glottis,  fainting,  failure  of  the  pulse,  or  respira- 
tory syncope? 

Stop  the  administration  of  the  chloroform,  lower  the  head  to 
an  angle  of  forty  degrees,  and  elevate  the  feet  above  the  level 
of  the  body,  and  remove  the  mucus  or  blood  that  may  collect 
in  the  mouth  during  the  operation.  Draw  out  the  tongue,  and 
retain  it  out  by  a  hgature,  Ketch  forceps,  or  dry  towel,  and  elevate 
the  jaw,  and  above  all  use  artificial  respiration,  keeping  it  up  for 
at  least  one  hour  if  necessary.  Administer  from  ten  to  twenty 
drops  of  nitrite  of  amjd,  if  the  face  is  pale,  but  not,  if  flushed; 
drop  from  a  bottle  on  a  piece  of  cloth  and  hold  it  to  the  nose 
and  mouth.  If  the  patient  make  no  efi'ort  to  breathe,  force  it 
up  the  nostrils  by  means  of  a  small  hand-spray  compressing 
apparatus,  and  expand  the  chest  by  manipulation  with  the 
elbows  to  the  side,  and  compress  the  chest.  This  should  be 
continued  until  the  heart  acts.  Flagellation  with  towel  wrung 
out  of  ice  water  is  very  useful,  but  do  not  chill  the  patient.  If 
there  is  still  increased  narcosis,  employ  hypodermic  injections 
of  water  of  ammonia  (containing  five  per  cent,  of  ammonia  gas) 
to  the  quantity  of  a  drachm  or  two,  or  solution  of  sulphate  of 
atropia.  But  depend  chiefly  on  lowering  the  head,  and  artifi- 
cial respiration  long  continued.  Grive  the  patient  plenty  of 
fresh  air  b}'^  opening  the  windows  ;  if  cold,  cover  with  blankets. 
Apply  a  galvanic  or  Faradaic  current  during  the  artificial  res- 
piration, one  electrode  to  the  base  of  the  neck  and  the  other  to 


A    NEW    WAY    OF    RAISIXO    THE    EPIGLOTTIS.       263 

the  epigastric  region,  on  a  line  with  the  diaphragm,  but  not  in 
the  region  of  the  heart  or  solar  i)lexus.     Let  the  assistants  or 
nurses  rub  the  extremities  briskly,  and  use  even  slight  blows, 
on  the  neck,  and  side  of  the  chest,  but  not  on  the  stomach. 

It  is  not  safe  to  continue  an  operation  immediately  on  a  pa- 
tient's recovery  from  the  excessive  action  of  anaesthetics,  but  to 
wait  until  respiration  has  been  energetically  restored  ;  otherwise, 
a  new  and  generally  fatal  asphyxia  may  be  produced.  It  is  well 
to  remember  that  angemia  of  the  brain  is  secondary  to  the  ces- 
sation of  the  heart's  action,  and  that  to  restore  vitality  to  the 
brain  requires  that  the  heart's  action  be  restored.  For  this 
purpose,  as  we  have  stated  before,  there  is  nothing  better  than 
lowering  the  head  and  artificial  respiration,  and  the  use  of  it  is 
to  be  continued,  not  onlj'  for  a  few  moments,  but  for  hours; 
indeed,  recoveries  have  occurred  after  the  use  of  the  Faradaic 
current  and  artificial  respiration  for  one  hour. 

It  has  been  clearly  proven  that  in  cardiac  and  respiratory 
failure,  the  pneumogastric  nerve  retains  its  excitability  in  chlo- 
roform poisoning,  and  it  is,  therefore,  extremely  dangerous  to 
apply  electricity  to  the  neck  in  this  condition.  (See  the  experi- 
ments and  observations  of  Doctors  Hare  and  Martin  on  the 
phrenic  nerve. ) 

A  J^ew  Way  of  Raising-  tlie  Epiglottis. 

Dr.  Howard,  of  London,  has  endeavored  to  prove  that  trac- 
tion of  the  tongue  cannot,  as  is  supposed,  raise  the  glottis,  but 
that  the  only  way  by  which  it  can  be  certainly  raised  is  by  ex- 
tension of  the  head  and  neck,  whereby  its  elevation  is  instant 
and  complete.  The  patient  is  brought  to  the  edge  of  the  bed, 
or  the  chest  is  elevated,  so  that  the  head  may  swing  free,  and 
with  one  hand  under  the  chin,  and  the  other  on  the  vertex, 
steadily,  but  firmly,  carry  the  head  backward  and  downward, 
until  the  most  possible  extension  of  the  head  and  neck  is  ob- 
tained. 

In  reference  to  the  above  paragraph,  we  addressed  a  letter  to 
Dr.  H.  A.  Hare,  knowing  that  he,  in  conjunction  with  Dr. 
Martin,  had  made  experiments  on  the  subject.     He  sent  us  the 


264  ARTIFICIAL    ANESTHESIA. 

following  article,  which  is  of  so  much  importance  that  we  have 
published  it  entire  for  the  benefit  of  those  who  may  have  an 
urgent  respiratory  crisis  in  anaesthetization. 

The  Treatment  of  Arrested  Respiration  in 
Anaesthesia.* 

"  In  a  paper  read  before  the  Medical  Society  of  London,  Dr. 
Benjamin  Howard  maintains  the  following  propositions  : 

"1.  The  epiglottis  falls  backward  in  apnoea,  and  closes  the 
glottis  ;  the  first  thing  in  order  and  importance  is  the  elevation 
of  the  epiglottis. 

"2.  Traction  upon  the  tongue,  however,  and  whatever  the 
force  employed,  does  not  and  cannot  raise  the  epiglottis,  as  sup- 
posed. 

"  3.  The  epiglottis  can  only  be  raised  by  extension  of  the 
head  and  neck. 

' '  4.  The  full  effect  of  extension  can  only  be  secured,  with 
certainty,  by  making  the  extension  complete,  as  directed. 

"  5.  The  method  of  making  extension  is  as  follows :  '  Having, 
by  bringing  the  patient  to  the  edge  of  the  table  or  bed,  or  by 
elevation  of  the  chest,  provided  that  the  head  may  swing  quite 
free,  with  one  hand  under  the  chin  and  the  other  on  the  vertex, 
steadily  but  firmly  carry  the  head  backward  and  downward; 
the  neck  will  share  the  motion,  which  must  be  continued  till 
the  utmost  possible  extension  of  both  head  and  neck  are  ob- 
tained. Sometimes  a  slight  elevation  and  extension  of  the  chin 
will  at  once  check  stertor,  or  irregularity  of  breathing;  but 
understand,  the  extension,  which  can  in  no  case  do  harm, 
should  always  be  rather  more  than  appears  necessary.  It  should 
never  be  forgotten,  however,  that  the  full  effect  of  extension, 
as  above  described,  can  be  secured  with  certainty  only  by  mak- 
ing the  extension  complete,  as  directed.' 

*  By  Edward  Martin,  M.D.,  Instructor  in  Surgery,  University  of 
Pennsylvania;  Surgeon  to  the  Philadelphia  Hospital  and  to  the 
Howard  Hospital ;  and  H.  A.  Hare,  M.D ,  Demonstrator  of  Thera- 
peutics, and  Instructor  in  Physical  Diagnosis,  in  the  Medical  Depart- 
ment, and  in  Physiology,  in  the  Biological  Department,  University 
of  Pennsylvania. 


THE    TREATMENT    OF    ARRESTED    RESPIRATION.       265 

"These  propositions  are,  in  some  respects,  so  contrary  to  the 
daily  experience  of  surgeons  and  anaesthetizers,  and,  if  well 
founded,  are  of  such  supreme  importance  in  cases  of  suspended 
animation,  that  we  have  conducted  a  series  of  experiments  de- 
signed to  test,  in  so  far  as  this  is  possible,  by  working  upon  the 
dead  body,  the  validity  of  Howard's  conclusions. 

"Limiting  our  inquiry  to  those  cases  of  threatened  death 
which  occur  from  respiratory  obstruction,  during  the  adminis- 
tration of  an  ansesthetic,  we  must  first  endeavor  to  discover  the 
mechanical  cause  which  is  principally  operative  in  producing 
such  obstructions.  We  presume  that  by  apnoea,  Howard  means, 
not  a  condition  of  suspended  respiratory  efforts  through  hyper- 
oxidation  of  the  blood,  which  is  the  true  significance  of  the 
term,  but  cessation  of  respiratory  movement.  We  cannot  be- 
lieve the  epiglottis  is  chiefly  at  fault  as  an  obstructive  agent, 
because,  in  the  vast  majority  of  cases,  the  air-passage  is  at  once 
made  free  by  drawing  the  tongue  forward  ;  since  tip-traction 
has  no  effect  upon  the  epiglottis,  as  stated  by  Howard  and  con- 
.firmed  by  our  own  observations,  this  manipulation  could  not 
relieve  the  breathing  were  the  epiglottis  the  cause  of  the  diffi- 
culty. The  effect  of  traction  upon  the  tip  of  the  tongue  is  to 
draw  this  organ  free  from  the  soft  palate  and  the  post-pharyn- 
geal  wall ;  it  is  the  tongue,  then,  fallen  back  upon  the  posterior 
wall  of  the  pharynx,  which  is  the  most  common  obstructing 
cause;  consequently,  the  tongue  should  receive  the  most  im- 
mediate consideration.  We  do  not  for  a  moment  deny  the 
possibility  of  respiratory  difficulty  being  caused  by  the  epiglot- 
tis alone,  though  experimentally  the  inward  passage  of  air  was 
very  little  influenced  by  any  position  of  the  epiglottis,  provided 
the  tongue  was  carried  well  forward  :  we  would  insist,  how- 
ever, upon  the  position  of  the  tongue  as  a  matter  of  prime  im- 
portance. Considering  next  the  effect  of  tongue-traction  upon 
this  epiglottis,  we  are  not  prepared  fully  to  indorse  Howard's 
statement.  Tip-traction  moves  the  epiglottis  not  at  all ;  this 
we  have  confirmed  by  many  trials,  both  in  the  living  and  in 
the  dead  subject ;  but  if  a  tenaculum  is  fixed  in  the  dorsum  of 
the  tongue  two  and  a  half  inches  back  from  the  tip,  traction 
at  once  draws  the  base  of  the  tongue,  and  the  epiglottis  with  it, 

18 


266  ARTIFICIAL    ANESTHESIA. 

far  forward,  so  that  the  air-passage  is  absolutely  free  from  the 
larynx  to  the  mouth.  Traction  can  then  be  so  applied  to  the 
tongue  that  the  epiglottis  is  raised  and  the  air-way  made  ab- 
solutely free,  and  we  have  devised  an  instrument  by  which  this 
may  be  accomplished  without  the  laceration  attendant  on  the 
use  of  hooks  or  forceps. 

"  Is  extension  of  the  head  and  neck  the  only  method  of  rais- 
ing the  epiglottis?  Again  we  are  compelled  to  take  exception 
to  Howard's  statement.  As  detailed  in  our  experiments,  the 
epiglottis  can  be  raised  by  traction  upon  the  dorsum  of  the 
tongue  by  pressing  the  greater  cornua  of  the  hyoid  bone  forward 
by  the  action  of  gravity  in  the  abdominal  decubitus,  and  most 
thoroughly  by  flexing  the  neck  and  extending  the  head  upon 
the  neck.  That  Howard's  position  accomplishes  mechanically 
all  that  he  claims  for  it,  we  freely  grant.  The  way  in  which 
the  soft,  collapsed  structures  straighten  under  his  manipulation, 
the  tongue  riding  forward  and  the  epiglottis  springing  erect, 
is  most  striking ;  and  we  are  convinced  that  the  admirable  me- 
chanical explanation  he  gives  for  this  effect  is  correct.  Howard 
states  : 

"'....  by  extension  of  the  head  and  neck,  carried  to  the 
utmost  completeness,  the  backward-fallen  tongue,  the  velum 
palati  and  uvula,  are  all  simultaneously  shifted  from  the  air- 
way, and  the  entire  pharynx  is  enlarged  throughout  as  fol- 
lows :  a.  The  tongue,  the  dorsum  of  which  before  fell  by  gravi- 
tation upon  the  then  horizontal  posterior  wall  of  the  pharynx, 
falls  upon  the  now  horizontal  arch  of  the  palate,  b.  The  velum 
palati,  by  means  of  the  great  tension  of  the  palato-pharyngeal 
muscles,  is  pulled  away  from  the  posterior  wall  of  the  pharynx, 
the  entire  membrane  being  stretched  tightly  forward  and 
downward,  behind  part  of  the  dorsum  of  the  tongue,  forming  a 
partition  which  helps  to  shut  the  tongue  out  of  the  pharynx 
and  into  the  mouth,  where  it  belongs,  and  with  part  of  the 
dorsum  forms  the  anterior  wall  of  a  new  post-oral  air-way, 
thus  created  and  maintained,  c.  The  pharynx,  anteriorly,  is 
stretched  far  forward  by  the  extremely  tense  sterno-thyroidei 
muscles  acting  through  the  thyroid  cartilage,  by  the  genio-hy- 
oidei  and  mylo-hyoidei  muscles,  acting  through  the  os  hyoidei. 


THE    TREATMENT    OF    ARRESTED    RESPIRATION.        267 

The  base  of  the  tongue  and  the  velum  palati  are  shifted  forward 
in  the  manner  alread}^  described,  the  posterior  nares  being 
shifted,  by  the  extension  of  the  head,  by  its  oecipito-vertebra^ 
articulation,  about  sixty  degrees.  Posteriorly,  the  wall  of  the 
pharynx  is  shifted  back  its  whole  length  by  the  extension  of  the 
cervical  vertebrae  upon  each  other,  in  all  about  thirty  degrees, 
extension  being  particularly  great  just  opposite  the  glottis. 
Thus  the  upper  air-way,  which  before  was  a  tortuous,  angular, 
flaccid  canal — barely,  and  if  at  all  uncertainly  permeable — is 
made  an  enlarged,  firm,  but  slightly  curved  tube,  free  through- 
out from  the  glottis  to  the  nares. ' 

"With  all  this,  except  the  backward  shifting  of  the  posterior 
wall  of  the  pharjmx  by  extension,  we  are  fully  in  accord.  We 
cannot,  however,  concede  that  his  practical  deduction  from  these 
facts  is  a  step  in  the  right  direction.  With  the  head  and  neck 
in  extreme  extension,  the  soft  palate  is  strapped  over  the  dor- 
sum of  the  tongue,  the  mouth  is  closed  from  the  pharynx  and 
the  entrance  of  air  to  the  lungs  depends  absolutely  upon  the 
condition  of  the  nostrils.  Can  it  be  considered  an  additional 
safeguard — an  improved  method — to  substitute  for  the  roomy 
mouth  an  air- way,  but  just  sufficient  at  the  best,  subject  to  an 
infinite  variety  of  obstructions,  varjdng  in  size  from  hour  to 
hour,  in  many  persons  absolutely,  and  permanently  occluded? 
Certainly  no  American  rhinologist  would  answer  in  the  affirma- 
tive. Hypertrophies,  polypoid  growths  and  vegetations  are  not 
the  rare  exception.  The  slightest  congestion  is  frequently  suffi- 
cient to  block  patulous  nares.  A  nostril  which  will  admit  the 
little  finger  of  the  surgeon,  when  the  patient  is  standing,  may 
become  completely  closed  when  the  head  is  placed  on  a  level 
with  the  body.  The  recumbent  or  dependent  position,  the 
irritating  effect  of  ether  upon  the  mucous  membranes,  cephalic 
congestion  due  to  insufficient  oxidation,  all  combine  to  render 
the  nostrils  unsafe — in  fact,  absolutely  impracticable — as  the 
sole  passage  of  communication  between  the  lungs  and  the  ex- 
ternal air.  We  cannot  believe  that  recourse  to  this  method,  in 
cases  of  suspended  animation  under  anaesthetics,  could  be  fol- 
lowed by  favorable  results ;  if  the  tongue  were  drawn  forward 
it  would  certainly  provide  ample  air-way,  the  passage  from  the 


268  ARTIFICIAL    ANESTHESIA. 

pharynx  to  the  mouth  being  opened  by  this  manipulation.  One 
of  the  great  advantages  of  this  method,  however,  as  claimed 
by  Howard,  is  that  the  necessity  for  traction  upon  the  tongue 
is  entirely  done  away  with.  If  the  necessity  for  drawing  for- 
ward the  tongue  is  not  done  away  with  we  cannot  see  that 
Howard's  method  offers  any  material  advantage  over  that  ordi- 
narily practiced  in  this  city. 

"Our  experiments  show  that  extension  of  the  head  carried 
so  far  that  the  base-line  (Reid's)  makes  an  angle  of  somewhat 
more  than  fifty  degrees  to  the  plane  of  the  bed,  or  table,  raises 
the  tongue  and  epiglottis  so  entirely  clear  of  the  posterior 
pharynx  that  there  is  ample  air-way ;  the  soft  palate,  too,  lies 
free  of  the  post-pharyngeal  wall,  but  is  not  drawn  closely  across 
the  dorsum  of  the  tongue,  thus  allowing  respiration  to  take 
place  through  the  mouth.  If,  in  the  course  of  an  anaesthetiza- 
tion,  there  is  respiratory  difficulty,  the  method  which  obtains 
here  is  as  follows :  The  chin  is  immediately  pressed  forward  by 
the  fingers  placed  behind  the  rami  of  the  lower  jaw  ;  at  the  same 
time,  and  by  the  same  manipulation,  the  head  is  extended,  the 
pillow,  if  any  has  been  used,  being  removed  ;  if  there  is  still 
apparent  obstruction  the  tongue  is  now  drawn  forward.  With 
this  manipulation,  except  in  case  of  foreign  body  or  abnormality 
of  structure,  the  air-passage  from  the  mouth  to  the  larynx  is 
absolutely  free.  Hereafter  we  may  modify  this  method,  so 
placing  the  pillow  that  the  neck  is  flexed  as  far  forward  as  pos- 
sible, then  extending  the  head  upon  the  neck,  as  we  find  that 
this  gives  us  wide  dilatation,  the  posterior  pharyngeal  wall  rep- 
resenting the  arc  of  a  circle,  from  the  concavity  of  which  exten- 
sion of  the  head  draws  forward  the  tongue,  epiglottis  and 
larynx.  In  the  method  as  detailed  above  it  rarely  occurs  that 
the  tongue  has  to  be  drawn  forward. 

"Finally,  we  cannot  grant  that  Howard  is  justified  in  believ- 
ing, of  the  hundred  cases  of  death  due  to  the  administration  of 
an  anaesthetic,  that  in  each  case  the  epiglottis  was  in  all  prob- 
ability unraised,  and  continued  unraised  until  death  was  com- 
plete. The  appearance  of  the  parts  after  death  cannot  be  taken 
as  indicative  of  their  relative  position  during  life — when  inspi- 
ratory efibrts  are  still  taking  place,  when  the  rigor  mortis  has  not 


THE    TREATMENT    OF    ARRESTED    RESPIRATION.        269 

made  the  surrounding  muscles  more  rigid  than  the  epiglottis. 
Again,  the  very  traction  upon  the  tongue,  as  usually  exerted, 
extends  the  head  sufficiently  to  carry  the  epiglottis  free  of  the 
post-pharyngeal  wall.  Finally,  where  inspiratory  efforts  are 
being  made,  there  is  no  difficulty  in  determining  whether  or  not 
air  is  entering  the  chest ;  the  noise  of  its  passage  through  the 
mouth  and  throat,  the  respiratory  sounds,  are  sufficiently  char- 
acteristic of  its  free  entrance ;  while  sinking  in  of  the  inter- 
costal spaces,  epigastrium,  and  suprasternal  region,  during  an 
inspiratory  effort,  are  absolutely  diagnostic  of  obstruction. 
These  signs,  though  not  so  patent,  are  still  sufficiently  clear  in 
artificial  respiration,  and  if  the  cause  of  death  were  even  in  the 
majority  of  cases  simply  obstructive,  this  condition  of  obstruc- 
tion would  unquestionably  have  been  recognized  and  remedied, 
if  not  by  position  certainly  by  tracheotomy  or  intubation. 

"The  results  of  our  examinations,  made  upon  several  cada- 
vers, are  as  follows  : 

"  By  chipping  away  the  basilar  process  of  the  occipital  bone 
the  naso-pharjmx  is  exposed. 

"Subject  in  the  dorsal  decubitus,  head  midway  between 
flexion  and  extension,  eyes  looking  directlj^  upward,  Reid's 
base-line  (from  the  lower  border  of  the  orbit  through  the  bony 
meatus)  at  right  angles  to  the  plane  of  the  table. 

"  The  tongue  lies  in  close  contact  with  the  posterior  wall  of 
the  pharynx,  only  the  tip  of  the  epiglottis  being  visible.  The 
soft  palate  and  the  dorsum  of  the  tongue  shut  the  mouth  from 
the  pharynx.  The  air-passage  is  completely  obstructed  by  the 
tongue  and  epiglottis, 

"By  means  of  a  tenaculum  passed  through  its  tip,  the  tongue 
is  seized  and  drawn  forward  as  far  as  possible.  The  body  of  the 
tongue  is  drawn  clear  of  the  post-pharyngeal  wall  and  the  soft 
palate  ;  the  hyoid  bone,  the  base  of  the  tongue  and  the  epiglot- 
tis are  not  at  all  influenced. 

"  The  tenaculum  is  now  fixed  two  and  a  half  inches  from  the 
tip ;  traction  draws  both  the  base  of  the  tongue  and  the  epi- 
glottis well  forward. 

"The  fingers  are  passed  behind  the  angles  of  the  lower  jaw, 
and  the  latter  is  pressed  forward  ;  this  elevates  the  epiglottis 


270  ARTIFICIAL    ANESTHESIA. 

and  the  base  of  the  tongue  about  a  quarter  of  an  inch  from  the 
post-pharyngeal  wall.  Extending  the  head  so  that  the  base- 
line makes  an  angle  of  forty-five  degrees  with  the  plane  of  the 
table,  draws  the  base  of  the  tongue  and  the  hyoid  bone  far  for- 
ward, this  motion  being  at  the  same  time  imparted  to  the  epi- 
glottis, so  that  the  latter  stands  upright,  and  is  separated  from 
the  posterior  wall  of  the  pharynx  by  an  interval  of  about  an 
inch.  By  tightly  closing  the  jaw,  the  antero-posterior  space  is 
still  further  increased. 

"The  body  is  drawn  to  the  end  of  the  table,  so  that  the  head 
hangs  free  ;  the  latter  is  now  extended  until  the  base-line  is  par- 
allel to  the  plane  of  the  table ;  the  antero-posterior  space  be- 
tween epiglottis  and  pharynx  is  slightly  greater  than  that  which 
obtains  from  moderate  extension.  At  the  same  time  the  tongue 
drops  toward  the  roof  of  the  mouth,  the  soft  palate  is  put  upon 
the  stretch,  and  the  mouth  cavity  is  shut  out  from  that  of  the 
pharynx. 

"  Placing  the  head  so  that  the  base-line  is  perpendicular  to 
the  plane  of  the  table  again  produces  complete  closure  of  the 
pharynx,  owing  to  the  tongue  and  epiglottis  falling  directly 
backward. 

"Placing  the  fingers  upon  the  posterior  cornua  of  the  hyoid 
bone,  and  pressing  the  latter  directly  forward,  carries  the  epi- 
glottis and  tongue  about  one-half  inch  forward  and  entirely  free 
of  the  post-pharyngeal  wall. 

"With  the  head  moderately  extended,  and  the  jaw  pushed 
forward,  an  effort  is  made  to  crowd  the  tongue  and  epiglottis 
against  the  post-pharyngeal  wall ;  this  is  found  to  be  impos- 
sible. 

"Flexing  the  neck  by  lifting  the  head  forward  (keeping  the 
base-line  perpendicular  to  the  plane  of  the  table)  separates  the 
post-pharynx  from  the  epiglottis  and  the  base  of  the  tongue  by 
about  one-half  an  inch.  Extending  the  head  upon  the  neck, 
the  neck  being  still  flexed,  produces  a  yet  wider  separation,  the 
antero-posterior  diameter  of  the  breathing  space  being  some- 
what more  than  one  inch. 

"Placing  the  body  in  the  position  of  abdominal  decubitus, 
the  base-line  being  perpendicular  to  the  plane  of  the  table,  the 


THE    TREATMENT    OF    ARRESTED    RESPIRATION.        271 

hyoid  bone,  base  of  the  tongue  and  epiglottis  all  fall  forward, 
leaving  an  interval  of  about  half  an  inch  between  the  epiglottis 
and  post-pharyngeal  wall. 

"On  elevating  the  shoulders,  by  seizing  them  and  lifting 
them  directly  upward,  this  space  is  increased  to  fully  an  inch  ; 
at  the  same  time  the  arytenoid  cartilages  are  drawn  backward, 
exposing  the  glottis  throughout  its  whole  extent. 

"  Bringing  the  body  to  the  end  of  the  table  and  letting  the 
head  droop  forward  (still  in  abdominal  decubitus),  thus  flexing 
the  neck  to  its  full  capacit3%  then  extending  the  head  at  the 
occipitoatloid  articulation,  exposes  the  larynx  more  completely 
than  any  of  the  previous  postures  or  manipulations. 

"Conclusions. — The  epiglottis  may  prevent  free  entrance 
of  air  to  the  lungs,  even  though  the  tongue  is  pulled  forward. 
Any  means  which  accomplishes  the  anterior  projection  of  the 
hyoid  bone,  immediately  and  infallibly  raises  the  epiglottis  and 
the  base  of  the  tongue. 

"  The  hyoid  bone  may  be  made  to  project  anteriorly  by  direct 
pressure  upon  its  cornua,  by  direct  pressure  or  traction  applied 
to  the  dorsum  of  the  tongue,  behind  the  anterior  half-arches  of 
the  palate,  by  the  action  of  gravity  in  the  abdominal  decubitus, 
or  by  extension  of  the  head  upon  the  neck. 

"Extension  of  the  head  upon  the  neck,  carried  as  far  as  forty- 
five  degrees,  produces  practically  as  patulous  a  condition  of  the 
air-way  as  forced  and  extreme  extension.  At  the  same  time 
this  moderate  extension  usually  leaves  sufficient  room  between 
the  palate  and  the  dorsum  of  the  tongue  for  breathing  to  con- 
tinue through  the  mouth. 

"  In  forced  extension  of  the  head  and  neck,  the  entrance  of 
air  into  the  lungs  depends  upon  the  sufficiency  of  the  nasal  pas- 
sages. 

"  Flexion  of  the  neck,  with  extension  of  the  head  upon  the 
neck,  does  away  with  the  epiglottis  as  an  obstructing  factor  as 
completely  as  any  other  posture.  This  is  best  accomplished  by 
supporting  the  head  upon  a  high  pillow,  then  pulling  it  di- 
rectly backward  by  the  hand  placed  under  the  chin,  so  that  the 
weight  of  the  head  falls  upon  the  occiput  rather  than  upon  the 
back  of  the  neck. 


272  ARTIFICIAL    ANESTHESIA. 

''Therefore,  in  case  of  an  urgent  respiratory  crisis  in  anaes- 
thetization,  we  would  direct  that  the  index  fingers  placed  behind 
the  greater  cornua  of  the  hyoid  bone,  and  the  middle  fingers 
resting  upon  the  angles  of  the  lower  jaw,  both  these  structures 
be  pressed  directly  forward,  the  same  force  also  serving  to  ex- 
tend the  head  upon  the  neck.  If  obstruction  to  breathing  still 
persists,  the  tongue  should  be  at'  once  drawn  or  pushed  forward 
by  force,  exerted  upon  its  dorsum  posterior,  to  the  anterior 
half-arches. 

"No  force,  unless  directly  applied  to  the  tongue  itself,  is 
sufficient  to  infallibly  prevent  this  organ  from  acting  as  an  ob- 
structing factor.  No  manipulation  yet  devised  can,  in  every 
case,  take  the  place  of  direct  action. 

"The  tongue  may  act  either  in  conjunction  with  the  pharyn- 
geal walls  or  with  the  palate,  in  preventing  free  entrance  of  air. 
If  the  position  of  moderate  extension  and  direct  traction  or 
pressure  upon  the  tongue  fail  to  remove  the  obstruction  to 
breathing,  intubation  or  bronchotomy  remains  as  the  last  re- 
sort. 

Apparatus  of  Martin  and  Hare  for  the  Treatment 

of  Cases  of  Arrested  Respiration,  and  their 

Conclusions  in  Injury  or  Destruction 

of  the  Phrenic  Nerve. 

"  The  apparatus  which  we  devised  for  use  in  a  case  where 
the  body  is  too  large  to  permit  of  the  operator  swinging  it,  as 
in  the  man  and  dog,  under  similar  circumstances  to  those 
named,  was  constructed  as  follows,  and  consisted  of  a  board 
supported  on  an  upright  of  equal  width  and  rounded  edge,  the 
horizontal  plank  resting  by  means  of  a  groove  on  its  under  sur- 
face upon  the  convexity  of  the  vertical  support.  To  this  hori- 
zontal board  is  then  bound  the  subject,  and  by  a  see-sawing 
movement  the  body  is  rapidly  changed,  so  that  at  one  moment 
the  head  is  down  at  an  angle  of  forty-five  degrees,  and  at  the 
next  moment  is  correspondingly  raised,  while  the  feet  fall.  In 
this  way  the  weight  of  the  abdominal  contents  is  thrown  against 
the  diaphragm  as  the  head  is  lowered,  and  the  air  in  the  thorax 
is  thereby  driven  out.     On  the  other  hand,  if  the  head  is  rap- 


CONCLUSIONS.  273 

idly  raised  and  the  feet  ftill,  the  abdominal  contents  drop  into 
the  pelvic  space,  dragging  the  diaphragm  after  them,  and 
thereby  producing  inspiration. 

"In  order  at  the  same  time  to  extend  the  chest,  as  the  ab- 
dominal contents  sagged  downwards,  we  were  forced  to  invent  a 
simple  apparatus  which,  by  means  of  cords,  raised  the  arms 
above  the  head  at  the  moment  that  the  feet  approached  the 
floor." 

Cunclusions. 

"  1st.  Injury  or  destruction  of  the  phrenic  nerves  is  not  fol- 
lowed by  death,  as  has  heretofore  been  taught. 

' '  2d.  That  in  injuries  involving  the  diaphragmatic  movements 
it  is  important  that  the  patient  shall  not  be  anaesthetized,  as 
under  those  circumstances  the  absence  of  voluntary  aid  in  respi- 
ration may  be  attended  by  fatal  results. 

"3d.  The  seriousness  of  phrenic  injury  is  in  direct  ratio  to 
the  dependence  of  the  respirations  of  the  normal  animal  on  the 
diaphragm,  and  to  the  ability  of  the  chest  walls  to  make  com- 
pensatory movement. 

"4th.  The  symptoms  resulting  from  interference  with  the 
functions  of  the  phrenic  nerves  are  as  definite  and  character- 
istic as  those  following  interference  with  any  other  motor 
nerve.  There  will  always  be  well-marked  increase  in  the  scope 
of  the  thoracic  excursions,  and  distinct  reversal  of  the  move- 
ments of  the  belly,  i.e.,  the  belly  will  retract  on  inspiration. 

"  5th.  Fear  of  injury  to  one  or  both  phrenic  nerves  need  not 
prevent  operations  about  the  neck  and  upper  portion  of  the 
chest,  provided  that  due  caution  be  exercised,  that  the  patient 
is  but  shghtly  under  the  influence  of  the  anaesthetic  at  the 
time,  that  danger  of  injury  to  these  nerves  is  most  imminent. 
Infancy,  however,  constitutes  an  exception  to  this  rule ;  only 
absolute  and  pressing  necessity  for  operation  would  afford  justi- 
fication for  such  a  procedure  in  early  life. 

"6th.  The  real  effects  of  section  of  the  phrenic  nerves  being 
known,  it  follows  that  the  nerve  is  subject  to  the  same  opera- 
tion in  case  of  injury  as  are  other  nerves  of  the  body,  such  as 
suture. 


274  ARTIFICIAL    ANESTHESIA. 

"7th.  The  presence  of  the  abdominal  viscera  are  necessary 
for  the  normal  movements  of  the  diaphragm. 

"8th.  The  abdominal  contents  may  alone  be  used  for  the  pro- 
duction of  artificial  respiration,  but  while  they  are  always  to  be 
employed  to  this  end  their  use  should  never  be  allowed  to  dis- 
place those  movements  which  are  directed  to  the  chest.  Both 
should  be  used  together  if  possible. 

"  9th.  In  cases  of  injury  to  the  phrenic  nerves  support  should 
be  given  to  the  belly  walls,  to  prevent  movement  of  the  same, 
and  to  brace  and  steady  the  paralyzed  diaphragm,  care  being 
taken  that  the  floating  ribs  are  free. 

"  10th.  The  method  of  Sylvester  drives  more  air  through  the 
lungs  than  any  other  single  method,  but  its  best  results  are  not 
gained  unless  the  feet  be  drawn  down  as  the  arms  are  extended. 

"  11th.  The  volume  of  respired  air  after  section  of  the  phre- 
nic nerves  is  temporarily  decreased  until  the  thorax  compensates 
for  the  loss  of  the  diaphragm. 

"  12th.  Oxygen  gas  is  a  valuable  agent  in  the  treatment  of 
persons  sufiering  from  coal-gas  poisoning. 

"  13th.  Oxygen  gas  aids  very  materially  in  bridging  over  the 
respiratory  crisis  occurring  after  injury  to  the  phrenic  nerves. 

"  14th.  In  life-saving  stations,  mines,  police  stations,  or  other 
points  to  which  asphyxiated  persons  may  be  brought  for  resus- 
citation, in  hospital  clinics,  or  in  private  houses,  where  ether  or 
chloroform  is  given,  oxygen  in  appropriate  form  for  immediate 
administration  should  be  provided.  The  accoucheur  also  will 
find  in  this  gas  a  valuable  adjunct  in  the  treatment  of  cases  of 
suspended  animation  in  the  newly  born.  Very  small  cylinders, 
containing  forty  gallons  of  the  compressed  gas,  are  easily  car- 
ried and  require  a  small  amount  of  space. 

"  15th.  The  electrical  methods  now  employed  for  the  resusci- 
tation of  persons  who  have  ceased  breathing  are  dangerous  and 
unjustifiable." 

On  the  Influence  of  Climate  and  Heat  on  the  Use  of 
Chloroform. — The  following  extracts  from  letters  of  distin- 
guished surgeons  in  the  South  will  show  the  influence  of  climate 
on  the  use  of  chloroform  : 

Dr.  Langdon  B.   Edwards,  editor  of  the    Virginia  Medical 


DANGERS  AND  TREATMENT  OF  FATAL  SYMPTOMS.       275 

Monthly,  October  21,  1878,  states  that  it  is  one  of  the  most  pe- 
culiar facts  he  has  ever  known  in  medical  practice— the  diifer- 
ence  of  experience  in  Europe  and  in  the  North  with  chloroform 
and  ether  as  compared  with  that  of  the  South— the  high  rate 
of  mortality  in  the  North  and  the  low  rate  in  the  South. 
Anaesthetics  are  used  for  more  trivial  affections  and  surgical 
operations  in  the  South  than  in  the  North,  and,  of  course,  for 
obstetrical  cases,  etc.  Even  during  the  war,  when  the  South- 
erners were  not  using  Squibb' s  ether,  or  a  chloroform  having 
the  reputation  of  such  purity,  their  preference  was  for  chloro- 
form, although  of  home  manufacture.  Had  a  case  that  was 
fatal  occurred  from  its  use  in  any  of  the  small  cities  or  towns  it 
would  have  become  wide-spread  news. 

The  operation  of  insertion  of  a  needle  into  the  heart  might 
excite  the  quiescent  organ  to  action,  while  again  it  might  cause 
a  feebly  beating  heart,  that  would  perhaps  recover  if  given  a 
chance,  to  become  hopelessly  inco-ordinated. 

Abstract  as    to  the  Dangers  and  Treatment  of 
Fatal  Symptoms  from  tlie  Use  of  Chlo- 
roform as  an  Anaesthetic. 

1st.  Failure  of  the  heart,  which  may  o.ccur  at  all  stages.  2d. 
From  reflex  inhibition  by  terror.  3d.  By  the  irritation  of  the 
vapor.     4th.  From  chloroform  idiosyncrasy. 

Symptoms. —Feeble,  fluttering  pulse;  pallor;  grayness  or 
blueness  of  the  face,  ears  and  fingers,  or  a  sudden  interruption 
or  complete  stoppage  of  the  heart  action. 

Treatment.— Careful  examination  of  the  heart,  lungs  and 
kidneys,  and  forbidding  chloroform  in  cases  of  atheromatous 
disease  of  the  vessels,  which  can  be  felt ;  fatty  degeneration  of 
the  heart,  with  great  pallor  of  skin  and  feebleness  of  action ; 
aortic  or  advanced  mitral  disease,  which  must  be  determined  by 
the  history  and  stethoscope.  If  the  symptoms  given  in  the 
first  part  are  present,  the  chloroform  must  at  once  be  removed, 
the  head  and  body  inverted,  first  removing  all  foreign  bodies 
from  the  mouth  ;  let  limbs  be  elevated  in  women  and  blankets 


276 


ARTIFICIAL    ANESTHESIA. 


well  wrapped  around  them,  or  the  body  inverted  over  the  knee 
of  an  assistant.  When,  as  occasionally  happens,  the  anaesthe- 
tizer  is  single-handed,  the  raising  of  a  patient  by  the  feet  is 
practically  out  of  the  question,  except  to  one  of  unusual 
strength.  Any  one  of  good  physique  is  able,  however,  to  ac- 
complish the  same  thing  quite  readily  by  placing  his  hands  be- 
neath the  patient's  hips,  and  raising  them  until  the  leg  can  be 
slipped  beneath,  and  the  patient  then  rests  upon  his  knee,  the 
foot  being  upon  the  bed.     The  head  and  shoulders  can  now  be 


Plate  4'/ 


Sylvester's  Method  of  Artificial  Eespiration. 

swung  off  the  bed,  and  at  need  the  patient,  from  the  head  to 
knees,  brought  into  a  vertical  position.  If  the  tongue  has  fallen 
back,  draw  it  forward,  and  keep  it  held  firmly  out  of  the  mouth. 
If  the  breathing  is  not  relieved,  an  assistant  employs  Sylves- 
ter's method  of  artificial  respiration  as  follows  :  The  operator 
stands  behind  the  patient  and  grasps  the  arms  near  the  axillae ; 
he  first  presses  the  arms  into  the  sides,  so  as  to  compress  the 
thorax  and  expel  air,  whilst  an  assistant  makes  gentle  pressure 
upon  the  abdomen.  Next,  he  firmly  draws  the  arms  away  from 
the  sides,  everting  them,  and  lifting  the  patient  as  the  arms  be- 


THE    EPIGLOTTIS    IN    CHLOROFORM    ACCIDENTS.       277 

come  about  45°  beyond  the  head.  Finally,  he  carries  the  arms 
back  to  a  line  with  the  head.  He  pauses  to  allow  air  to  rush 
freely  into  the  lungs,  and  then  brings  the  arms  down  to  the 
sides  as  before.  This  process  is  repeated  twelve  or  sixteen 
times  in  a  minute. 

Forced  respiration  is  stated  to  be  an  advance  upon  artificial 
respiration,  and  will  save  human  life  where  the  latter  will  fail. 
According  to  Dr.  Geo.  E.  Fell,  of  Buffalo,  N.  Y.  {Journal 
Amencan  Medical  Association^  October,  1889),  the  apparatus 
consists  of  a  bellows  to  supply  a  steady  stream  of  air,  which 
passes  through  an  air-heating  apparatus-;  an  air-valve  which 
controls  the  ingress  of  air  to  the  lungs,  and  is  connected  by  an 
elastic  tube  and  tracheotomy  tube  in  the  neck  and  trachea  of  the 
patient. 

The  Epiglottis  in  Chloroform  Accidents. 

Dr.  A.  E.  Prince,  in  N.  Y.  Med.  Jour. ,  says  :  "  As  an  illus- 
tration of  the  uncertain  knowledge  which  exists  upon  the  sub- 
ject, may  be  cited  the  belief  that  drawing  out  the  tongue  will 
raise  the  epiglottis,  and  thus  open  the  air-way  to  the  lungs. 
This  belief  exists  in  the  minds  of  a  large  proportion  of  the  pro- 
fession, and  the  procedure  is  employed  and  recommended  by 
many  leading  surgeons.  By  way  of  correcting  the  error,  refer- 
ence is  here  made  to  a  demonstration,  by  Benjamin  Howard, 
before  the  Roj^al  College  of  Surgeons,  England,  the  conclusions 
drawn  from  which  are  :  First,  contrary  to  the  universal  belief, 
traction  of  the  tongue  cannot  raise  the  epiglottis ;  second,  by 
sufficient  extension  of  the  head  and  neck,  whether  bj'^  volition, 
instinct,  reflex  action  or  by  effort  of  another,  whether  in  the 
healthy,  in  the  djang  or  in  the  dead,  the  epiglottis  is  instantly 
and  beyond  prevention  made  completely  erect ;  third,  by  a  com- 
plete extension  of  the  head  and  neck  the  tongue  and  velum,  as 
respiratory  obstructions,  are  removed  simultaneously  with  the 
epiglottis,  and  without  a  moment's  delaj^  the  entire  air-way 
may  be  straightened  and  made  free  throughout  by  the  nearest 
person." 

We  copy  this  article  because  it  differs  from  the  well  received 
idea. 


278  ARTIFICIAL    ANESTHESIA. 

Resuscitation  by  Anal  Dilatation. 

Dr.  L.  C.  Grosvenor,  of  Chicago,  in  the  Journal  of  Orifickd 
Surgery,  August,  1893,  gives  an  unique  as  well  as  amusing  ac- 
count of  three  cases  of  resuscitation  by  means  of  forcible  dila- 
tation of  the  anal  orifice.  The  first  case  was  a  man  dying  from 
an  over-dose  of  morphine.  The  second  was  the  arousing  of  an 
infant  born  asphj'xiated,  while  the  third  was  that  of  infantile 
eclampsia.  His  modus  operandi  is  to  grease  the  thumbs  of 
either  hand  and  proceed  to  dilate  the  sphincter.  He  thinks 
this  process  acts  as  a  direct  stimulant  through  the  sympathetic, 
and  believes  it  might  be  successfully  applied  in  resuscitating  the 
drowned  where  the  spark  of  life  is  not  quite  extinct. 

Brunton  on  Chloroform. 

After  the  reading  of  Dr.  Wood's  paper  on  Anaesthesia,  Dr. 
T.  Lauder  Brunton,*  in  introducing  the  discussion  of  the  subject 
of  chloroform  narcosis  to  the  Berlin  Congress,  spoke  as  follows  : 
"Does  danger  to  life  during  chloroform  narcosis  arise  from 
failure  of  the  heart  or  failure  of  the  respiration,  and  how  is 
such  danger  to  be  averted?"  After  tracing  the  nature  of  the 
early  investigations  for  the  discovery  of  the  toxic  effects  of 
chloroform,  he  concluded  :  "I  grant  at  once  that  chloroform  is 
a  protoplastic  poison.  I  have  rendered  the  muscles  of  an  ani- 
mal as  stiff  as  a  piece  of  wood  by  injecting  it  into  the  artery  of 
a  lamb.  I  have  stopped  the  pulsations  of  an  animal's  heart  by 
blowing  chloroform  vapor  directly  into  the  lungs.  But  what  I 
wish  to  maintain  is,  that  notwithstanding  all  this,  when  chloro- 
form vapor  is  inhaled  in  the  usual  way  by  inspiratory  efforts  of 
the  patient  himself,  it  does  not  stop  the  heart,  but  first  acts 
upon  the  respiratory  centre,  and,  by  stopping  the  breathing, 
prevents  a  quantity  of  chloroform,  sufficient  to  stop  the  heart, 
from  reaching  that  organ." 

This  we  consider  false  reasoning  on  the  part  of  this  distin- 
guished experimenter,  and  is  the  old  doctrine  of  Syme  and  the 

*  Abridged  from  his  paper,  The  Lancet,  August  16,  1890,  p.  351. 


BRUNTON    ON    CHLOROFORM.  279 

Edinburgh  School.  Listen  to  him  when  he  informs  us  of  the 
time  between  the  respiration  and  its  action  on  the  heart  :  "We 
may  saj',  then,  that  the  time  of  grace  is  only  half  a  minute^  and 
if  the  administrator's  attention  should  be  so  distracted  as  to 
allow  this  half  a  minute  to  elapse  after  the  respiration  has 
ceased,  the  patient  will  probablj''  die." 

It  is  evident,  then,  that  constant  attention  to  the  respiration 
is  required  ;  and,  indeed,  this  was  the  great  lesson  taught  us 
by  our  experiments.  When  chloroform  was  inhaled  with  free 
admixture  of  air,  it  usually  produced  a  fall  of  blood-pressure  to 
some  extent,  but  the  administration  of  chloroform  may  be  con- 
tinued for  a  long  time  without  much  further  fall,  provided, 
always,  that  plenty  of  air  be  given  with  it.  If,  however,  chlo- 
roform vapor  be  given  with  a  deficient  quantity  of  air,  the  fall 
of  blood-pressure  is  very  rapid,  the  cardiac  pulsations  become 
slow  and  irregular,  and  shortlj''  cease  altogether. 

This  irregularity  is  well  shown  in  the  tracing  of  the  Glasgow 
committee,  from  which  thej^  draw  these  conclusions,  that 
chloroform  depresses  the  heart,  and  does  so  irregularly,  and  in 
an  unforeseen  manner.  The  tracing  is  evidently  one  of  slow 
pulse  due  to  irritation  of  the  vagus.  In  numerous  experimental 
attempts  to  irritate  the  vagus.  Dr.  Brunton  did  not  succeed  in 
reproducing  the  tracings,  but  on  simpl^''  closing  the  animal's 
mouth  and  nostrils,  or  closing  the  opening  of  the  tracheal 
canula  when  one  had  been  introduced,  he  was  able  at  once  to 
reproduce  the  tracing.  He  was  able  to  produce  such  curves 
both  when  the  animal  was  thoroughly  under  chloroform  and 
when  it  was  completel^^  out  of  chloroform. 

He  found,  that  with  pressure  upon  the  chest,  death  occurred 
very  rapidly  from  the  administration  of  chloroform.  This  is  a 
very  important  hint,  both  to  the  assistants  and  the  operator 
also,  to  avoid  tight  clothing  or  the  corset  in  the  care  of  ladies ; 
and  this  is  applicable  in  the  use  of  all  angesthetics.  Examina- 
tion of  both  heart  and  the  urine  is  of  vital  importance. 

The  question,  he  states,  is  still  unsettled,  and  cannot  be 
finally  settled  either  from  a  purely  clinical  or  the  purely  experi- 
mental side.     Both  must  be  worked  up  together,  and  to  this 


280  ARTIFICIAL    ANESTHESIA. 

end  the  London  Lancet  has  sent  out  a  circular  asking  for  infor- 
mation regarding  all  cases  of  death  from  chloroform.  When 
all  the  deaths  from  chloroform  have  been  completely  tabulated, 
their  causes  may  be  interpreted  by  the  light  of  experiments. 

An  abstract  of  the  first  of  these  we  produce,  and  this  from  a 
Scotch  surgeon  of  eminence  : 

"  Statistics  show  that  the  fatalities  attributed  to  chloroform 
cannot  be  explained  by  the  condition  of  the  patient's  previous 
health,  the  severity  of  the  operation,  or  the  result  of  the 
autopsy." 

More  Recent  Views  in  Keg-ard  to  the  Action  of 
Anaesthetics. 

Conclusions  of  a  report  of  the  action  of  chloroform,  with  a 
criticism  of  the  second  Hyderabad  Commission,  by  W.  H.  Gas- 
kill,  M.D.,  F.R.S.,  Lecturer  on  Physiology  in  the  University  of 
Cambridge,  andL.  E.  Shore,  M.D.,  Demonstrator  of  Physiology 
in  the  University  of  Cambridge.* 

The  principle  upon  which  Lawrie  administers  chloroform  may 
be  summed  up  in  a  single  sentence  :  "Never,  at  any  moment 
of  the  administration  of  chloroform,  administer  it  in  so  concen- 
trated a  form  as  to  cause  irregularity  of  respiration,  and  cease 
the  administration  as  soon  as  complete  anaesthesia  has  been  in- 
duced."  The  danger,  then,  of  chloroform  administration  con- 
sists (1)  of  causing  a  serious  fall  of  blood-pressure,  owing  to 
weakening  the  heart  from  too  great  a  percentage  of  chloroform 
in  the  air,  which,  in  its  turn,  causes  failure  of  respiration  ;  and 
(2)  cessation  of  respiration  after  long  administration,  although 
given  with  plenty  of  air,  after  anaesthesia  has  been  established. 

A  more  recent  criticism  by  Dr.  Brunton,  of  London,  states, 
as  a  result  of  his  physiological  experiments,  that  respiration  is 
affected,  causing  asphyxial  condition  of  the  blood,  the  com- 
bined action  of  chloroform  and  asphyxia  affecting  the  heart. 

The  Action  of  Chloroform. — Dr.  Lauder  Brunton,  after  going 
over  the  experiments  of  Drs.  Gaskell,  Shore  and  others,  reaches 

"••■  British  Medical  Journal,  February  4,  1893. 


ACTION    OF    ANAESTHETICS RECENT    VIEWS.       281 

the  following  conclusions  :  (1)  That  Drs.  Gaskell  and  Shore  are 
mistaken  in  regard  to  the  fall  in  blood-pressure  produced  by  chlo- 
roform as  the  most  important  question  connected  with  its  action. 
(2)  That  the  conclusions  of  the  Hyderabad  Commission  are  en- 
tirely unaffected  by  their  criticism,  which  is  directed  to  two 
things  :  (a)  the  effect  of  chloroform  injected  into  the  jugular  vein 
and  (b)  the  pulse  tracings  obtained  during  chloroform  narcosis. 
In  regard  to  (a),  the  error  into  which  "Gaskell  and  Shore  "  sup- 
pose the  commission  to  have  fallen  was  suspected  by  the  com- 
mission, and,  as  they  believe,  was  avoided.  In  regard  to  (b), 
the  criticism  of  Drs.  Gaskell  and  Shore,  it  is  not  directed  against 
the  conclusions  of  the  commission,  but  against  the  comments 
made  in  the  course  of  describing  individual  experiments.  The 
tracings  thus  criticised  were  not  considered  as  satisfactory  evi- 
dence by  the  commission,  and  were  consequently  not  emplo3^ed 
by  them  as  a  basis  for  their  conclusions.  (3)  That  they  have 
devised  a  most  ingenious  plan  of  experiment  by  cross  circula- 
tion and  have  obtained  many  interesting  results.  While  these 
experiments  may  afford  much  valuable  information,  they  are  not 
entirely  free  from  fallacy,  as  they  were  not  performed  on  ani- 
mals under  chloroform  influence  alone,  but  with  either  morphine 
or  chloral.  (4)  That  they  entirely  confirm  the  conclusions  of  the 
Hyderabad  Commission,  that  the  chief  danger  from  chloroform 
is  the  concurrence  of  asphj^xia,  and  that  the  most  important 
practical  point  is  attention  to  respiration,  as  maintained  by 
Syme  and  Lister. 

We  feel,  like  Dr.  Wood,^  that  Dr.  Brunton  has  in  his  recent 
publication  given  away  the  whole  case  of  the  Hyderabad  Com- 
mission, as  follows  : 

"  As  every  one  knows,  the  Hyderabad  Commission,  the  great 
supporter  of  the  exclusiveness  of  respiratory  death,  derived  most 
of  its  authority  from  the  presence  on  the  Board  of  Lauder  Brun- 
ton, of  London,  who  in  a  recent  publication  says  :  'If  we  drive 
chloroform  into  the  trachea,  or  air  very  heavily  loaded  with 
chloroform  vapor  into  the  lungs  by  artificial  respiration,  it  will 
be  absorbed  in  sufficient  quantities  to  paralyze  the  heart. '    This 

*  Anaesthesia,  by  Dr.  H.  C.  Wood. 
19 


282  ARTIFICIAL    ANESTHESIA. 

is  a  practical  giving  away  of  the  whole  case  of  the  Hyderabad 
Commission,  at  least  as  I  have  understood  it,  and  as  I  believe  it 
to  have  been  understood  by  the  general  profession.  However 
this  may  be,  it  is  a  confession  that  the  chloroform  death  is  not 
of  necessity  due  to  asphyxia,  so  that  it  must  be  admitted,  first, 
that  both  ether  and  chloroform  may  kill  the  man  or  the  lower 
mammal  either  by  arrest  of  respiration  or  by  syncope  ;  second, 
that  syncopal  death  from  chloroform  is  not  common,  though  it 
does  occur  in  the  lower  animals,  but  is  not  rare  in  man  ;  third, 
that  the  difference  between  ether  and  chloroform,  so  far  as  the 
mode  of  death  is  concerned,  is  that  that  form  of  death  (synco- 
pal) which  is  common  under  the  influence  of  chloroform  is  rare 
under  the  influence  of  ether. ' ' 

Resuscitations  by  Lingual  Tractions.* 

Members  of  the  Royal  Navy  having  frequently,  when  at  sea, 
to  consider  the  best  means  to  resuscitate  the  drowning,  and  our 
coast  guards  having  to  rescue  people  by  means  of  the  Board  of 
Trade's  rocket  apparatus  and  coast  ladder  appliance,  it  struck 
me  that  a  few  observations  might  be  of  use  to  the  readers  of  the 
United  Service  Gazette^  with  the  view  of  dispelling  the  hitherto 
erroneous  views  which  have  been  too  commonly  accepted  anent 
resuscitation. 

Dr.  J.  Y.  Laborde,  Professor  of  Physiology  at  the  Paris 
Faculty  of  Medicine,  according  to  his  own  accounts,  has  founded 
a  French  school  of  enthusiastic  inquirers  and  experimenters 
who,  in  extraordinary  and  apparently  hopeless  cases — cases 
where  it  was  alleged  that  all  other  methods  of  artificial  respira- 
tion and  the  like  had  failed — nevertheless  resuscitated  many 
still-born  infants  and  adults  apparently  dead.  In  his  recently 
published  treatise,  he  and  his  followers  declare  that  already,  up 
to  March  20,  1894,  they  had  saved  sixty-three  lives,  which,  ac- 
cording to  their  own  statements,  were  all  rescued  by  Laborde's 
methods  of  repeated,  long-continued,  persistent  lingual  trac- 
tions, or  pulling  the  tongue  outwards,  downwards  and  forwards 

*  By  J.  Lawrence  Hamilton,  M.E.C.S.  Reprinted  from  tlie  United 
Service  Gazette,  August  11,  1894. 


RESUSCITATIONS    BY    LINGUAL    TRACTIONS.         283 

at  the  rate  of  from  fifteen  to  twenty  or  more  tractions  to  the 
minute,  movements  that  are  accredited  with  having  special 
powers  to  excite  contractions  of  the  diaphragm,  to  promote  the 
suspended  powers  of  the  respirator}^  reflex.  Laborde  suggests 
that  death  is  absolute  where  repeated  lingual  tractions  fail  to 
restore  animation. 

In  the  accidental  asphyxia  or  syncope  noticed  in  experiment- 
ing upon  animals,  especially  on  dogs,  above  all  where  anaesthe- 
tics had  been  administered,  in  French  laboratories  presided  over 
by  Dr.  Laborde,  the  first  operation  was  to  seize  the  tip  of  the 
tongue.  Thereby  not  only  were  the  laryngeal-pharyngeal  tracts 
opened,  but  repeated  rhythmical  retractions  as  a  rule  resulted 
in  the  return  of  respiration,  which  followed  close  upon  a  series 
of  loud  hiccoughs. 

At  first  these  noisy  hiccoughs  responded,  as  it  were,  passively 
to  the  artificial  lingual  tractions,  but  later  the  respiration  became 
automatic  and  spontaneous. 

In  the  Royal  Medico-Chirurgical  Transactions,  vol.  Ixxii., 
Dr.  Bowles  has  shown  that,  in  apparent  death  from  drown- 
ing, in  the  supine  or  horizontal  position,  the  paralyzed  tongue, 
by  letting  its  base  drop  backwards,  thereby  blocks  up  the 
pharynx. 

Although  it  hooks  up  the  dropped  base  of  the  tongue, 
nevertheless  Laborde's  method  fails  to  remove  the  frothy 
water,  often  nmco-sanguineous — with  or  without  mud,  sand 
and  the  like — from  the  water-logged  lungs,  and  perhaps  also 
the  abnormal  contents  of  the  stomach  and  oesophagus,  which 
may  also  be  more  or  less  filled  with  somewhat  similar  foreign 
materials. 

In  every  case,  first  put  the  patient  in  a  suitable  position  to 
allow  of  the  immediate  escape  of  these  fluids  from  his  chest,  in 
which  procedure  pulling  the  dropped  base  of  the  tongue  for- 
wards is  pressingly  urgent. 

In  a  much  condensed  form.  Dr.  Laborde's  Tractions  Rhyth- 
mees  de  la  Langue  might  be  worth  translating  into  and  publish- 
ing in  English ;  but  then  only  if  the  well-known  up-to-date  work 
of  others,  including  that  of  Dr.  Alexander  Morison,  were  added 
to  Dr.  Laborde's  investigations. 


284  ARTIFICIAL    ANESTHESIA. 

John  Hunter's  1776  historical  paper  on  resuscitation,  by  means 
of  his  specially  constructed  bellows  inflated  with  air  or  with 
oxygen,  is  not  even  mentioned  by  Dr.  Laborde  ! 

His  book  ignores  references  or  even  allusions  to  the  best  liter- 
ature and  past  experimental  research  on  the  resuscitation  of  men 
and  animals,  which  greatly  detracts  from  the  value  of  Dr. 
Laborde' s  far  too  one-sided  observations  and  vague  conclu- 
sions. 

Some  of  Dr.  Laborde's  cases  of  alleged  resuscitations  of  still- 
born children  would  doubtless  have  spontaneously  recovered 
without  medical  assistance. 

Dr.  Champney's  elaborate  experiments,  published  in  1887,  on 
the  artificial  respirations  of  still-born  children,  could  be  advan- 
tageously studied  by  Professor  Laborde,  as  well  as  Taylor  and 
Stevenson's  (1894)  Deaths  from  Secondary  Causes  after  Suc- 
cessful Resuscitations. 

In  all  cases  of  attempted  resuscitation  and  of  first  aid  in 
ambulance  drills  to  restore  suspended  animation,  added  to  the 
usual  methods  of  resuscitation,  Laborde's  method  should  be 
tried,  though  to  rely  on  it  solely,  as  advocated  and  implied  by 
Dr.  Laborde,  would  be  indeed  foolish  and  frequently  fatal. 

Rhythmic  Traction   of  the   Tong-ue  in  Accidents. 
The  Asphyxia  from  Chloroformization.* 

We  come  now  to  speak  of  chloroformic  intoxication,  to 
which  belongs  the  primitive  accident  of  cardiac  syncope  or 
that  of  respiration,  or  both  occurring  at  the  same  time,  which 
so  often  mark  the  beginning  of  the  administration  of  chloro- 
form in  surgical  ansesthetization,  or  which  constitute  one  of  the 
episodes  during  the  anaesthesia. 

It  is  precisely,  as  we  can  doubtless  recall,  in  these  conditions, 
that  we  have  experimentally  determined  the  application  of  this 
procedure  of  rhythmic  traction  of  the  tongue  in  treating  chlo- 
roformic accidents,  and  these  are,  really,  its  point  of  departure 

*Les  Tractions  Eythmees  de  la  Langue.  Par  I.  V.  Laborde^ 
Directeur  des  Travaux  Physiologiques  a  la  Faculte,  Membre  de 
I'Academie  de  Medecine.    Paris,  1894.    Translation. 


RHYTHMIC    TRACTION    OF    THE    TONGUE.  285 

and  its  origin.  It  is  by  the  aid  of  systematic  lingual  traction 
that  we  have  conquered,  in  our  laboratory,  all  conditions  of 
snycope  or  accidental  asphyxia  following  chloroformic  or  chlo- 
ral anaesthesia.  No  doubt  the  same  results  would  have  fol- 
lowed the  same  treatment  in  surgical  operations. 

We  have  received  in  this  connection  another  fact  (of  which 
there  will  soon  be  mention)  from  Dr.  Filiget,  hospital  surgeon 
—the  account  of  a  case  in  his  own  practice  which,  in  regard  to 
the  procedure  of  which  it  treats,  presents  a  real  interest.  (See 
on  this  subject  an  interesting  observation  of  Dr.  Gigard,  of  the 
Cote  St.  Andre,  Isere,  published  in  the  Med.  Tribune,  No.  12, 

1894.) 

In  August,  1883,  M.  Filiget,  substituting  for  M.  Lariboisur^, 
had  occasion  to  operate  on  a  patient— Jules  Broe— for  cancer  of 
the  superior  left  maxillary.  He  practiced  preparatory  trache- 
otomy and  administered  ether  by  the  trachea.  In  the^  course 
of  the  operation  a  respiratory  syncope  supervened,  with  ap- 
parent death.  Traction  of  the  tongue  was  immediately  resorted 
to  and  recalled  the  patient  to  life. 

I  am  convinced,  in  fact,  and  have  already  remarked  in  former 
communications,  that  simple  traction  of  the  tongue  beyond  the 
mouth,  such  as  has  been  resorted  to  by  surgeons  for  a  long  time, 
with  the  end  in  view  of  freeing  the  back  part  of  the  throat,  as 
one  might  say  the  speaking  tongue,  from  being  drawn  back  by 
the  excitation  and  contraction  caused  by  chloroform— that  this 
traction  can,  I  say— and  has  in  certain  cases  done  so— restore 
respiration.  This  is  demonstrated  in  the  preceding  case  of  Dr. 
Filiget' s,  but  it  would  not  suffice  in  advanced  cases  of  asphyxia 
following  chloroformization  with  apparent  death.  It  is  neces- 
sary to  add,  reiterated  and  persistent  rhythmic  tractions  consti- 
tute the  true  and  systemic  procedure  in  question. 

The  majority  of  surgeons  who  are  acquainted  with  this 
method  do  not  fail  now  to  use  this  treatment  at  the  first  evi- 
dence of  danger  from  chloroformization,  and  we  know  that  m 
a  certain  number  of  cases,  of  which  it  is  to  be  wished  that  the 
operators  themselves  might  publish  them,  the  gravest  accidents 
and  probably  more  or  less  imminent  death  habitually  occurring 
in  such  conditions  have  been  averted. 


286  ARTIFICIAL    ANESTHESIA. 

We  give  below  two  cases  of  this  nature,  of  which  one  has 
been  published  in  a  medical  journal  and  the  other  comes  from 
one  of  OUT  colleagues. 

"An  operation  was  performed  two  days  since  at  the  Hospital 
of  St.  Andrew  of  Bordeaux,  by  Dr.  Dennea,  upon  a  patient 
suffering  from  neoplasm  of  the  larynx,  the  anaesthetic  used 
being  chloroform,  with  a  centigramme  of  morphia,  where  this 
procedure  of  Dr.  Laborde's  succeeded,  although  all  respiration 
was  suspended,  and  the  patient  blue,  almost  black,  from  as- 
phyxia. Although  the  canula  had  been  placed  in  the  trachea, 
respiration  did  not  return.  Rhythmic  tractions  of  the  tongue 
were  made  persistently,  respiration  returning  at  first  irregularly 
but  later  perfectly. ' ' 

Professor  E.  Masse  added  to  his  account  of  the  case  the  fol- 
lowing remarks : 

"Dr.  Laborde  has  certainly  given  us  here  a  most  beautifu 
result.  It  cannot  be  contested  that  he  was  successful  in  restor- 
ing respiration  in  this  subject  in  a  state  of  asphyxia  from  the 
combined  action  of  chloroform  and  of  stenosis  of  the  larynx. 
This  method,  while  not  excluding  all  others,  gives  us  another 
arm  upon  which  to  lean,  and  which  seems  to  give  naturally  the 
best  results  in  accidents  from  the  use  of  chloroform. 

"Dr.  Laborde  has  often  used  this  treatment  during  opera- 
tions upon  animals.  Every  one  knows  that  complete  asphyxia 
frequently  occurs  in  dogs  under  chloroformic  inhalation.  After 
ten  minutes'  traction  of  the  tongue  he  has  often  restored  ani- 
mals when  they  were  in  a  state  of  complete  asphyxiation.  He 
gives  the  following  observations  of  his  friend  and  colleague,  Dr. 
Meniere,  of  the  National  Institute  of  Deaf  Mutes  : 

"'Apparent  Death  Following  Chloroformization. — 
Recalled  to  life  of  rhythmic  traction  of  the  tongue.  Your 
remarkable  work  upon  rhythmic  traction  of  the  tongue  in  the 
case  of  apparent  death  has  interested  me  greatly.  Since  your 
presentation  to  the  Academy  of  your  observations  upon  this 
subject  are  multiplying,  permit  me  to  offer  one  of  which  I  know 
personally. 

"'Observation  XIII. — Last  month  one  of  my  little  pa- 
tients of  the  Dispensary  Furtado-Hine  presented  an  external 


RHYTHMIC    TRACTION    OF    THE    TONGUE.  287 

caries  of  the  mastoid,  caused  by  an  osteo-periostitis  following 
an  old  chronic  otorrhoea.  Operation  was  plainl}'  indicated. 
It  was  necessary  to  make  a  complete  curettage  of  the  region. 
One  of  my  residents,  who  was  quite  aufait  in  anaesthetic  prac- 
tice, gave  the  chloroform.  The  child  slept  easily,  nothing  par- 
ticular occurring  to  note. 

"  'The  operation,  of  eight  minutes,  was  finished,  and  I  was 
about  to  pass  a  drain  when  I  noticed  that  the  patient  was  not 
breathing.  No  beating  of  the  heart,  no  pulse,  no  respiration. 
The  face  was  cadaverous  in  color. 

"' Immediately  the  child  was  put  upon  the  table  with  his 
head  hanging  over,  and  one  of  my  internes  resorted  at  once  to 
artificial  respiration.  At  the  same  time  I  seized  the  tongue 
with  pincers,  and  made  in  continued  fashion  rhythmic  traction 
of  the  tongue,  as  you  have  described.  It  was  six  minutes  be- 
fore the  first  physiological  inspiration  was  evident.  We  con- 
tinued the  tractions  and  artificial  respiration  during  a  moment 
longer,  and  the  child  was  saved. 

"'I  am  convinced  that  the  tractions  rendered  me  here  a 
veritable  service. 

"  'I  can  only  repeat,  apropos  of  this,  what  I  said  in  one  of 
my  first  communications  to  the  Academy  on  this  subject.  (No- 
vember 22,  1892.) 

"'In  the  case  of  chloroformic  accidents  by  respiratory  or 
cardiac  syncope,  or  of  both  together,  the  procedure  of  the 
tongue  can  be,  as  in  experimental  chloroformization,  the  most 
powerful  means  and  the  quickest  of  resuscitation,  not  only  by 
putting  the  tongue  out  to  free  the  back  part  of  the  mouth,  but  of 
making  with  it  repeated  and  rhythmic  tractions  until  the  appear" 
ance  of  a  hiccough,  the  precursor  of  returning  respiration.'  " 

NoTE.^As  we  go  to  press,  we  received  from  one  of  our 
colleagues  in  Algeria,  Dr.  Mosiman,  Ex-Medicia  Major  in  the 
Army  and  Chief  of  Clinics  of  Val-de-Grace,  one  of  the  most 
remarkable  cases  of  recalling  to  life  by  lingual  traction  made 
upon  a  young  man  operated  for  haemorrhoids,  he  being  in  a 
state  of  apparent  death  from  chloroformization.  ''I  am  per- 
suaded," he  declares,  "that  had  I  not  known  this  procedure,  I 
should  have  lost  my  patient." 


288  ARTIFICIAL    ANiESTHESIA. 

Dr.  Perrier,  Surgeon  to  the  Lariboisiere  Hospital,  also  gives 
a  case  in  his  practice  equall^^  successful  under  like  circum- 
stances. 

On  the  Iiija^uence  of  Cliloroforin  in  Producing-  Tis- 
sue Chang-es,  Such  as  Fatty  Degeneration  of 
the  Heart,  of  the  Diaphragm  and  Other 
Striated   Muscles,    and   also  of  the 
Parenchyma  of  the  Liver  and 
Kidneys. 

As  early  as  1850,  Casper  stated  that  chloroform  produced 
chronic  poisoning,  and  later  Liman  afl&rmed  that  after  prolonged 
chloroformization  patients  pass  into  an  abnormal  condition 
which  continues  for  days,  even  for  weeks,  and  finally  ends  in 
death.  These  views  were  confirmed  by  R.  Unger,*  who  reports 
as  the  result  of  his  investigations,  pursued  since  1883,  that  the 
inhalation  of  chloroform  produces  fatty  degeneration  of  the 
heart,  of  the  diaghragm  and  other  striated  muscles,  and  also  of 
the  parenchyma  of  the  liver  and  kidneys. 

He  was  also  of  the  opinion  that  protracted  inhalation  of  chlo- 
roform vapor,  during  tedious  operations,  may  thus  produce  a 
state  of  weakness,  in  which  a  second  inhalation  may  prove  fatal, 
though  the  patient  apparently  tolerates  the  first  inhalation 
without  dangerous  symptoms.  For  this  reason  he  opposes  the 
use  of  chloroform  in  normal  child-birth. 

These  results  were  confirmed  by  Dr.  Strassman,t  in  his  experi- 
ment on  dogs,  who  found  that  the  first  organ  to  be  affected  was 
the  liver,  then  the  heart,  and  after  that  the  other  viscera.  He 
states  that  the  nature  of  the  morbid  change  was  not  fatty  de- 
generation, but  fatty  infiltration. 

The  actual  cause  of  death  in  fatal  cases  appeared  to  be  the 
cardiac  affection,  as  in  all  such  a  very  marked  degree  of  change 
was  found  in  the  heart.  In  non-fatal  cases  the  morbid  change 
was  found  to  have  disappeared  in  a  few  weeks'  time.  When 
morphine  was  given  previously  to  chloroform  less  of  the  latter 

*  E,  Unger  (5  Cent,  fiir  Chir.,  Artificial  Anaesthesia,  Turnbull,  3d 
Edit.,  p.  462,  1890). 
t  Turnbull,  Manual  of  Anaesthetics,  3d  Edit.,  p.  490. 


PERILS    OF    CHLOROFORM    ADMINISTRATIONS.       289 

was  required,  and  consequently  the  changes  produced  were  not 
so  considerable  as  when  the  ordinary  amount  was  given. 

Animals  suffering  from  hunger,  loss  of  blood,  etc. ,  were  espe- 
cially predisposed  to  the  morbid  changes  due  to  the  chloroform. 

These  researches  were  further  confirmed  by  experiments  on 
animals  by  Ostertag,  Kast  and  Mester.  A  more  important  de- 
parture was  made  by  Dr.  Eugene  Fraenkil,  by  a  careful  study 
upon  four  human  subjects,  dying  after  prolonged  chloroformiza- 
tion,  who  found  a  wide-spread  necrotic  degeneration,  associated 
with  a  disposition  of  much  pigment  in  all  parts  of  the  body, 
but  especially  affecting  the  hearty  muscle  and  the  epithelmm  of 
the  kidney. 

In  summing  up  these  various  experiments.  Prof.  H.  C.  Wood 
and  Dr.  W.  S.  Carter*  state,  in  further  confirmation  of  the 
powerful  influence  of  chloroform  on  nutrition — there  are  also 
the  observations  of  Salkowski — that  marked  increase  in  the 
output  of  nitrogenous  waste  is  caused  by  the  administration  of 
the  drug  to  dogs  ;  of  Kast  and  Mester,  that  there  is  a  marked 
increase  in  the  elimination  of  chlorine  and  nitrogen  produced 
by  the  anaesthetic ;  and  of  Petruschcy,  that  after  death  from 
chloroform  the  intercellular  juices  become  rapidly  acid. 

Ostertag  in  his  conclusions  differs  somewhat  from  Unger  in 
believing  that  the  fatty  degeneration  is,  in  part,  due  to  the  de- 
struction of  the  red -corpuscles  by  the  chloroform.  As,  however, 
he  also  believes  that  the  destruction  of  the  protoplasm  is,  in 
part,  affected  by  the  direct  influence  of  the  chloroform,  the 
difference  between  his  views  and  those  of  Unger  is  not  vital. 
Moreover,  whatever  of  scientific  interest  may  attach  to  the 
method  in  which  chloroform  produces  its  ravages  to  the  sur- 
geon, the  method  is  of  little  practical  importance,  the  vital  fact 
being  that  chloroform  itself  directly  or  indirectly  destroys  the 
living  protoplasm  in  almost  all  proportions  of  the  human  body. 

Perils  of  Cliloroforiii  Administrations  in  Dental 
Operations. 

If  a  patient  is  not  thoroughly  under  the  influence  of  chloro- 
form any  irritation  of  the  fifth  nerve  would  produce  slowing  of 

*  Copied  from  original  Essay.     MSS.,  1896. 


290  ARTIFICIAL    ANAESTHESIA. 

the  heart's  action,  and  finally  stoppage  through  the  pneunio- 
gastric  nerve.  This  has  been  clearly  shown  by  experiments  on 
rabbits.  This  may  account  for  the  deaths  in  the  dental  chair 
from  operations  on  teeth.  Chloroform  is  the  most  powerful  of 
the  anaesthetics ;  too  much  caution  cannot  be  written  and 
taught,  that  the  heart  power  is  most  seriously  reduced  by  its 
action,  and  that  it  is  incapable  of  supplying  the  brain  properly 
unless  the  patient  is  in  the  recumbent  posture. 

The  researches  of  Richardson,  Rabuteau,  and  others,  have 
shown  that  the  physiological  action  of  chloroform  increases  in 
intensity  and  danger  as  the  number  of  carbon  atoms  increase, 
so  that  while  wood  spirit  (methyl  alcohol),  with  but  a  single 
atom  of  carbon,  is  transient  and  slight  in  its  eiFects,  those  of 
fusel  oil  (pentyl  alcohol),  which  has  five  atoms  of  carbon,  are 
prolonged  and  severe. 

Chloroform  Given  Improperly. 

The  fact  that  teeth  have  been  extracted  under  chloroform, 
and  without  injury  to  the  patient,  does  not  justify  its  use  for 
this  purpose.  The  surgeon  that  would  seat  a  patient  in  a  chair 
and  give  chloroform  to  amputate  a  finger,  or  even  open  an  ab- 
scess, would  be  guilty  of  negligence  short  of  criminality  ;  but 
much  more  culpable  is  he  who  performs  so  simple  an  operation 
as  the  extracting  a  tooth  in  this  position.  We  are  too  much 
inclined  to  excuse  blunders,  hoping  that  the  blunderers  have 
been  taught  a  salutary  lesson,  which,  however,  is  of  no  benefit 
to  the  person  who  has  come  to  an  untimely  death.  There 
should  be  more  care  in  dealing  with  the  ills  which  flesh  is  heir 
to,  so  that  the  patient  survives  the  treatment.  It  is  a  well- 
recognized  rule,  that  a  patient  should  never  immediately  assume 
the  upright  posture,  especially  after  the  use  of  chloroform, 
whose  chief  depressing  influence  is  upon  the  heart,  as  by  plac- 
ing the  head  low,  the  blood  returns  to  the  brain  and  heart,  and 
the  patient  is  safe.  This  well-known  method  of  Nelaton  has  had 
to  be  employed  in  several  instances  in  the  same  case,  and  thus 
saved  the  life  of  the  patient.  The  heart  of  every  patient  should 
be  examined  before  a  systemic  anaesthetic  is  employed,  and  to  a 
patient  with  fatty  heart,  chloroform  should  never  be  given. 


THE    EMPLOYMENT    OF    NITRITE    OF    AMYL.        291 

It  is  now  beginning  to  be  observed  by  the  profession  generally 
that  there  is  something  of  very  material  importance  in  the 
manner  in  which  anaesthetics  are  administered  ;  that  there  is 
an  anaesthetic  art  deserving  careful  study  and  application  in 
practice.  It  is  not  an  uncommon  observation  to  see  the  admin- 
istration of  the  anaesthetic  intrusted  without  discrimination  to 
an  assistant  who  holds  the  paper  cone  carelessly  over  the  pa- 
tient's face,  and  watches,  in  the  meantime,  the  various  steps  of 
the  operation.  Can  it  be  wondered  that,  in  a  process  involving 
such  essential  physiological  functions,  dangerous  and  alarming 
symptoms  arise  and  escape  notice  under  these  circumstances? 
Unquestionably,  the  administration  of  the  anaesthetic  should 
receive  the  undivided  attention,  during  an  operation,  of  one 
who  has,  by  study  and  training,  acquired  a  knowledge  of  the 
proper  method  of  administering  the  agent,  and  who,  in  danger, 
will  be  prepared  to  act  promptly  and  intelligently  in  his  efforts 
at  restoration. 

The  Employment  of  Nitrite  of  Aniyl. 

Being  desirous  of  knowing  some  of  the  more  obscure  points 
in  regard  to  the  way  in  which  the  nitrite  had  been  used  in  a 
case  of  death  from  chloroform,  we  wrote  to  Dr.  Taylor,  address- 
ing the  following  questions  :  Did  the  nitrite  of  amyl  produce  a 
flushing  of  the  face,  action  of  the  heart,  and  diflficult  breathing 
when  you  employed  it  yourself?  Did  you  use  a  tube  to  force  it 
up  the  nostrils  when  the  breathing  had  ceased?  How  many 
drops  were  employed  ?  Was  it  in  capsules  or  dropped  from  a 
bottle? 

The  doctor  kindly  replied  as  follows  : 

Richmond,  May  31,  1878. 
Doctor  Turnbull  : 

Dear  Sir  :  Your  letter  dated  May  20th  found  me  out  of  the 
city  for  a  few  days.  I  am  very  glad  to  answer  your  inquiries. 
You  say  that  "  Professor  Nekton's  method  will  sometimes  fail, 
especially  when  morphia  has  been  used  with  the  chloroform." 
No  morphia  was  given  at  the  time  with  the  chloroform.     It 


292  ARTIFICIAL    ANESTHESIA. 

was  during  the  sickness  that  large  quantities  had  been  adminis- 
tered. In  regard  to  the  amyl  used,  it  was  made  by  Squibb, 
and  was,  I  think,  pure.  I  am  sorry  I  cannot  find  a  sample  of 
it  to  send  you  for  examination.  It  was  dropped  from  a  bottle 
upon  a  handkerchief.  The  number  of  drops  was  not  ascer- 
tained. No  tube  was  introduced  into  the  nose. 
Very  respectfully,  etc. , 

Hugh  M.  Taylor.  *" 

The  number  of  deaths  from  chloroform  which  have  occurred 
up  to  date  will  be  seen  in  our  tables.  It  will  be  seen  by  a 
glance  how  and  why  deaths  from  chloroform  have  occurred, 
and  how  unsatisfactorily,  in  most  of  the  cases,  the  facts  con- 
nected with  the  circumstances  have  been  reported. 

In  our  last  edition  we  have  entered  into  detail  concerning 
such  deaths  (with  table)  from  chloroform.  In  this  later  edition 
we  have  detailed  but  a  few. 

*  We  do  not  think  the  doctor  quite  justified  in  the  use  of  so  power- 
ful an  anaesthetic  in  so  trifling  an  operation  as  external  perineal 
urethrotomy.  The  nitrite  of  amyl  was  not  employed  until  the  patient- 
had  become  unable  to  inhale  it.  His  conclusionsf  are  not  the  most 
recent,  as  a  careful  reading  of  our  table  of  deaths  from  it  will  show. 
It  gives  but  little  warning  before  it  kills  the  patient. 


t  See  full  account  of  case,  p.  426,  3d  edition  of  Manual. 


DEATHS  FROM  CHLOROFORM  AND  ETHER.    293 


CHAPTER    IX. 

Table  of  Deaths  from  Chloroform,  and  Ether,  since  the  Hyderabad 
Ck)minissions,  with  Conclusions— From  1888  to  1895  inclusive. 

We  live  in  an  age  of  wonderful  progress ;  in  nothing  is  this 
better  proven  than  in  the  multiplication  of  new  and  valuable 
books.  The  works  of  even  one  5'ear  becoming  almost  obsolete, 
new  editions  and  new  works  taking  their  place.  This  is  also 
the  case  with  original  experiments  and  investigations,  crowding 
out  the  old.  Nothing  is  lacking  in  either  men  or  money.  Two 
of  the  most  munificent  works  of  this  kind  have  recently  been 
undertaken  in  even  far-ofi"  India,  the  sum  of  ten  thousand  dol- 
lars having  been  spent  by  the  Nizam  of  Hyderabad  in  experi- 
ments on  anaesthetics  alone.  This  large  sum  was  given  owing 
to  the  devoted  efforts  of  Surgeon-Major  Lawrie,  of  the  Army 
of  India,  who  is  a  great  admirer  and  believer  in  the  opinions 
held  by  the  late  Professors  Sj^me  and  Simpson,  of  the  Edin- 
burgh School,  in  regard  to  chloroform. 

There  were  two  Commissions,  one  held  in  1888,  in  which  141 
dogs  were  killed  by  chloroform  inhalation,  and  the  symptoms 
and  results  of  careful  post-mortems  were  made.  The  chief 
conclusions  which  were  arrived  at  were  "that  it  is  impossible 
for  chloroform  vapor  to  kill  dogs  by  acting  primarily  on  the 
heart,  and  this  holds  good,  no  matter  in  what  doses  or  in  what 
manner  the  poisoning  is  induced. "  These  conclusions  having 
been  received  with  doubt  by  many  physiologists,  and  more 
especially  by  the  editors  of  the  London  Lancet,  led  to  a 
Second  Commission,  and  Dr.  Lauder  Brunton,  a  well-known 
author  and  physiologist,  was  added  to  the  Commission.  The 
conclusions  of  the  Second  Commission  were  published  January 
19,  1890.  About  six  hundred  animals,  chiefly  dogs,  were 
employed  in  the  investigations. 

The  experiments  of  the  committee  were  designed  to  show 
the  effect  upon  the  blood-pressure,  heart  and  respiration  of  the 


294  ARTIFICIAL    ANESTHESIA. 

inhalation  of  chloroform,  ether  and  the  A.  C.  E.  mixture,  ad- 
ministered in  various  ways  and  under  varying  conditions.  The 
subjects  of  the  Commission  were  five  in  number: 

1.  To  test  the  suitability  and  safety  of  chloroform  as  an 
anaesthetic.  The  experiments  with  ether  and  the  A.  C.  E. 
mixture  were  instituted  principally  for  the  sake  of  comparison 
with  chloroform  on  certain  points,  and  it  is  not  pretended  that 
they  afford  a  complete  exposition  of  the  action  of  those  agents 
on  the  system. 

2.  The  effect  of  pushing  the  above-named  anaesthetics  (a)  to 
a  dangerous  degree,  and  more  especially  until  the  respiration 
ceases ;  (b)  until  death  results. 

3.  The  modifications  in  the  effects  of  these  anaesthetics 
which  result  from  (a)  asphyxia  in  varying  degrees  and  produced 
by  various  means  (b)  from  the  use  of  drugs,  such  as  morphine, 
atropine,  physostigmine  and  others. 

4.  The  reality  or  otherwise  of  the  alleged  liability  during 
ordinary  chloroform  administration  to  the  occurrence  of  pri- 
mary or  secondary  syncope  or  stoppage  of  the  heart,  brought 
about  either  by  shock  or  through  fatty  or  weak  heart,  or  by 
haemorrhage,  or  by  changes  in  the  position  of  the  body.  To 
investigate  these  points,  in  the  first  place  a  large  number  of 
operations,  which  are  reported  to  be  especially  dangerous  in 
reference  to  shock,  were  performed  in  every  stage  of  anaes- 
thesia, and  numerous  experiments  were  also  made  to  show  the 
effect  of  direct  irritation  of  the  vagus.  Secondly,  a  number  of 
animals  were  dosed  with  phosphorus  before  they  were  experi- 
mented on.  This  caused  the  weakening  of  the  heart  by  fatty 
degeneration  of  its  fibres,  but  at  the  same  time  other  compli- 
cated changes  in  the  whole  of  the  organs  of  the  body,  not  met 
with  in  the  condition  known  as  fatty  heart  in  human  beings. 
On  the  other  hand,  there  are  conditions  often  found  in  the 
fatty  heart,  such  as  changes  of  the  coronary  vessels,  which  were 
not  produced  by  the  phosphorus. 

5.  The  effects  of  the  anaesthetics  above  mentioned  upon 
different  animals,  more  especially  upon  monkeys,  as  the  nearest 
approach  to  human  beings. 

In  brief,  the  practical  conclusions  arrived  at  as  to  the  effects 


DEATHS  FROM  CHLOROFORM  AND  ETHER.    295 

of  chloroform,  "that  in  every  instance  the  respiration  stopped 
before  the  heart,"  and  all  that  was  necessary  for  safety  was  to 
attend  to  that  alone.  Soon  after  the  publication  of  the  views 
thus  expressed,  several  practical  chloroform ists  gave  their 
opinion,  founded  on  professional  experience,  that  chloroform 
was  by  no  means  to  be  considered  safe  by  simply  attending  to 
the  respiration,  and  that  the  heart  still  played  a  most  import- 
ant part  in  the  deaths,  as  may  be  seen  from  the  numerous 
deaths  from  syncope  given  in  our  tables. 

With  this  view  I  have  made  a  most  careful  collection  of  all 
the  deaths  both  from  chloroform  and  ether,  from  every  avail- 
able source,  assisted  by  several  friends.  These  deaths  have 
been  arranged  in  a  tabular  form,  giving  the  name,  age,  history, 
nature  of  operation,  anaesthesia  used,  amount  used,  apparatus 
employed,  posture,  how  long  under  influence,  whether  heart 
or  respiration  stopped  first,  means  to  resuscitate,  how  long  con- 
tinued, post-mortem,  cause  of  death  and  references,  except  in 
a  few  instances. 

The  result  of  examinations  and  analysis  of  the  table  will  be 
found  on  pages  following. 

The  exceedingly  small  number  of  deaths  from  ether  demon- 
strates its  great  safety ;  still,  as  it  will  and  does  kill  (and  we 
notice  that  the  feeble  and  persons  suffering  from  malignant  dis- 
ease are  more  apt  to  be  its  victims,  see  IS'os.  10,  11  and  18),  we 
would  advise  its  use  as  an  anaesthetic  and  a  full  study  and  knowl- 
edge of  the  best  modes  of  using  it,  which  we  judge  is  not  the 
case  in  Europe. 

It  is  true  that  "chloroform  acts  more  rapidlj'  than  ether,  is 
pleasanter  to  take,  causes  less  congestion  of  blood  in  the  veins, 
is  much  more  portable  and  handy."  The  last  two  qualities 
render  it  preferable  in  certain  classes  of  operations,  e.g.^  in 
those  on  the  eye  and  in  military  or  travelling  establishments. 
On  a  campaign  it  would  be  impossible  to  find  room  to  carry  ether 
or  time  to  use  it. 

Again,  ether  cannot  be  used  in  hot  climates  or  in  close  prox- 
imity to  artificial  light ;  nor  is  it  suitable  in  certain  conditions 
of  the  lungs,  because  ether  is  more  apt  to  cause  suffocation  than 
chloroform,  which  is  given  with  a  much  greater  admixture  of 


296  ARTIFICIAL    ANESTHESIA. 

air.  Against  these  advantages  on  the  side  of  chloroform  ether 
has  only  one,  which,  however,  is  sufficient  to  outweigh  them  all 
— it  is  safer. 

With  regard  to  occasional  unexplained  deaths  under  chloro- 
form, it  must  be  remembered  that  they  occur  also  under  ether, 
though  not  so  frequently,  and  used  to  occur  in  a  similar  way  be- 
fore the  use  of  anaesthetics  at  all.  Dr.  Brunton  also  had  several 
accidental  deaths,  but  in  every  case  "the  usual  chloroformist 
was  absent,  and  no  one  was  attending  to  the  chloroform"  — 
a  most  significant  statement.  How  often  might  the  same  be 
said  (with  a  stress  on  the  word  "attending")  in  our  hospital 
practice.  The  Hyderabad  conclusions  really  imply  a  tremendous 
indictment  against  the  administrators  of  chloroform — nothing 
less  than  that  of  causing  death  by  carelessness.  Unhappily,  no 
one  familiar  with  the  administration  of  anaesthetics  can  doubt 
that  there  is  some  ground  for  this.  How  else  account  for  the 
widely  differing  records  of  different  administrators  ?  Every 
surgeon  knows  that  with  good  chloroformists  he  is  perfectly  con- 
fident and  easy,  with  others  the  reverse.  The  last  word  has  by 
no  means  been  said  upon  this  controversy  ;  but  if  we  may  ven- 
ture a  prophecy,  it  is  that  the  answer  to  the  question,  "Is 
chloroform  safe?"  will  eventually  be,  "That  depends  on  who 
gives  it. ' ' 

We  have  proofs  in  opposition  to  the  experiments  and  state- 
ments of  the  Commission,  that  chloroform  may  arrest  the 
heart  before  arrest  of  respiration.  In  one  experiment  breath- 
ing continued  two  minutes  after  the  heart  had  ceased  to  act. 

The  Pulse  During  Chloroform  Anesthesia. —A  case 
in  point,  in  which  chloroform  so  depressed  the  pulse  that  ether 
had  to  be  resorted  to.  The  British  Medical  Committee  (1890) 
on  anaesthetics,  after  examining  the  kymographic  tracings  taken 
by  the  Hyderabad  Commission,  cannot  agree  with  the  Hydera- 
bad Commission  in  holding  that  there  is  no  danger  to  the  heart 
during  the  administration  of  chloroform.  Both  committees 
have  found  that  death  occurs  by  failure  of  respiration  in  the 
great  majority  of  cases,  and  that  chloroform  causes  a  gradual 
fall  of  blood  pressure,  which  in  itself  is  a  source  of  danger. 
Both  have  also  observed  that  in  addition  to  this  gradual  fall 


DEATHS  FROM  CHLOROFORM  AND  ETHER.    297 

there  may  be  sudden  and  unexpected  falls,  with  slowing  of  the 
heart ;  but  as  to  the  explanation  of  these  falls  they  differ.  The 
Hyderabad  Commission  holds  that  these  falls,  during  which  life 
is  in  jeopardy,  are  caused  by  asphyxia,  while  the  British  Medi- 
cal Association  Committee  affirm  that  they  are  due  to  failure  of 
the  heart,  due  to  a  specific  action  of  the  chloroform  upon  the 
organs  (from  which  ether  is  free).  The  general  conclusion  of 
the  British  Medical  Association  Committee  is,  that  while  recog- 
nizing the  great  value  of  the  work  done  by  the  Hyderabad 
Commission,  and  more  especially  as  aided  by  Dr.  Lauder  Brun- 
ton,  they  consider  that  the  commission  attach  too  much  import- 
ance to  the  most  common  mode  of  death  from  chloroform — 
failure  of  respiration — and  fail  to  recognize  the  danger  to  the 
heart  that  may  arise  in  certain  physiological  conditions.  They 
consider  it  unwise  and  unsafe  in  practice  to  pay  no  attention  to 
the  state  of  the  circulation,  and  to  observe  respiration  alone. 
Further,  they  consider  it  unwise  to  convey  to  the  public,  even 
through  the  profession,  the  notion  that  there  is  practically  no 
danger  in  the  administration  of  chloroform."^  In  the  Man- 
chester Medical  Chronicle,  January  7,  1891  (page  276),  Dr.  Law- 
rie,  President  of  the  Hyderabad  Chloroform  Commission,  makes 
the  following  statement  in  answer  to  Alexander  Wilson  and 
others  in  their  reviews  of  the  Hyderabad  Commission,  pub- 
lished in  the  Chronicle  of  February  9,  1890.  Wilson  concludes 
his  review  as  follows  :  "  Increased  knowledge  has  added  nothing 
new  to  the  direction  for  its  (chloroform)  administration."  Law- 
rie  states :  "The  Hyderabad  Commission  was  appointed  to  con- 
firm or  disprove  Syme's  and  Simpson's  principles  that  we  should 
be  guided  as  to  the  effect  of  chloroform  entirely  by  the  respira- 
tion. The  commission  has  not  only  proved  that  these  princi- 
ples are  sound,  but  has  also  proved  that  the  art  of  administering 
chloroform  with  safety  consists  in  keeping  the  breathing  abso- 
lutely regular  throughout  the  inhalation."  This  proof  is  new, 
and  has  never  been  established  before.  After  criticising  the 
teachings  of  Wilson,  he  states  that  the  commission  has  shown, 
1,  that  the  lowering  of  the  blood-pressure,  which  chloroform 
and  all  anaesthetics  cause  when  efficiently  administered,  is  in 

*  British  Medical  Journal,  Editorial,  June,  1890. 
20 


298  ARTIFICIAL    ANESTHESIA. 

itself  a  harmless  event  if  the  respiration  alone  be  attended  to 
and  taken  as  a  guide,  and  if  the  administration  be  stopped  when 
the  patient  is  fully  anaesthetized ;  and  2,  that  the  sudden  falls 
of  pressure,  which  the  Glasgow  Committee  asserted  are  dan- 
gerous and  attributed  to  chloroform,  are  due  to  stimulation  of 
the  vagus,  and,  by  slowing  the  circulation,  are  a  safeguard 
against  overdoing. 

The  commission  further  proved  that  all  irregularities  in  the 
fall  of  the  blood-pressure  and  in  the  circulation  under  chloro- 
form, including  such  an  irregularity  as  dilatation  of  the  heart, 
which  occurs  when  chloroform  is  administered  properly,  are 
due  to  improper  administration  with  irregular  breathing  and 
insufficient  air  (page  277).  Again  (page  278),  every  medical 
man  ought  to  be  able  to  give  a  dose  of  chloroform  with  as  much 
precision,  as  certainly  as  a  dose  of  morphine  or  of  any  other 
poison.  The  practical  outcome  of  the  disastrous  teachings  of 
the  (rlasgow  Committee,  backed  up  by  Professors  Wood  and 
MacWilliam,  is,  that  the  relief  of  pain  by  chloroform  is  to  be 
handed  over  to  the  specialists,  who  alone  are  to  administer  it, 
though  their  own  declarations  and  statistics  show  that  they  can- 
not give  it  with  safety.  Exactly  in  proportion  as  this  teaching 
gains  ground,  the  profession  suffers  loss  in  credit  and  in  pocket, 
and  the  advantages  which  chloroform  confers  are  most  seriously 
restricted  and  curtailed. 

The  extensive  experiments  of  the  Commission  have  left  the 
chloroform  question  in  the  following  condition : 

It  was  not  found  possible  to  directly  paralyze  the  heart  (of 
dogs)  by  chloroform  in  some  600  administrations.  Death  from 
chloroform  is  due  apparently  from  paralysis  of  the  vaso-motor 
and  respiratory  centres — probably  one  or  both  of  these  may  be 
affected.  When  death  occurs,  it  is  the  result  of  an  overdose  of 
the  drug. 

The  most  conclusive  statements  and  experiments  are  given 
in  the  paper  of  Dr.  MacWilliam  in  answer  to  the  strictures  and 
conclusions  published  by  Dr.  Lawrie. 

"In  the  Medical  C/iromc?e,*  January,  1891,  Surgeon-Major 

*  Medical  Chronicle,  Manchester,  1891,  xiii.,  352-355. 


DEATHS  FROM  CHLOROFORM  AND  ETHER.   299 

Lawrie,  in  an  article  on  the  Hyderabad  Chloroform  Commis- 
sion, makes  some  comments  on  certain  results  obtained  by  me 
in  a  recent  investigation  on  the  action  of  chloroform  and  ether 
published  in  the  British  Medical  Journal,  October  11,  18  and 
25,  1890. 

"  In  my  paper  I  described  the  frequent  occurrence  of  dilata- 
tion of  the  whole  heart  under  the  influence  of  anaesthetic  doses 
of  chloroform.  Such  dilatation  was  not  due  to  changes  in  the 
pulmonary  circuit,  or  to  fall  of  arterial  pressure." 

Dr.  Lawrie  urges  that  the  cardiac  dilatation  was  due  to  ob- 
struction of  the  circulation  of  the  lungs,  or  to  this  along  with 
a  fall  in  the  blood-pressure.  He  saj's  :  "The  irregularities  in 
the  tracings  of  the  Griasgow  Committee,  and  Professor  Mac- 
William's  recent  bogie  of  dilatation  of  the  heart,  are  due  to 
obstruction  of  circulation  in  the  lungs  through  interference 
with,  or  irregularity  of,  the  respiration."  And  later:  "Ob- 
structed circulation  in  the  lungs,  and  a  rapidly  falling  blood- 
pressure,  are  more  than  enough  to  account  for  the  dilatation  of 
the  whole  heart,  which  occurred  in  his  experiments,  and  which 
he  wrongly  attributed  to  the  direct  action  of  chloroform. 

"Nor  can  this  hypothesis  of  Surgeon-Major  Lawrie's  be 
briefly  and  conclusively  disposed  of  There  is  an  abundance  of 
decisive  evidence  available.  First,  as  regards  the  alleged  influ- 
ence of  obstruction  of  the  circulation  in  the  lungs,  in  causing 
dilatation  of  the  heart.  In  my  paper,  in  the  Bntish  Medical 
Journal,  I  stated  the  fact  that  such  an  explanation  was  incom- 
petent to  explain  the  cardiac  condition,  since  the  whole  organ 
was  dilated  in  my  experiments.  Dilatation  of  the  right  side  of 
the  heart  might  conceivably  (if  there  were  no  evidence  to  the 
contrary)  be  accounted  for  by  the  pressure  of  pulmonary  ob- 
struction, but  dilatation  of  the  left  side  {e.g.  the  left  auricle) 
could  clearly  not  be  accounted  for  in  the  same  way,  since  pul- 
monary obstruction  necessarilj^  diminishes  in  a  large  measure 
the  flow  of  the  blood  into  the  left  auricle,  and  this  part  becomes 
small  and  collapsed.  This  seemed  so  obvious  to  me  that  I  did 
not  discuss  the  matter  at  any  great  length." 

I  shall  now  state,  briefly,  some  facts  in  regard  to  Surgeon- 
Major  Lawrie's  hypothesis  of  obstructed  circulation  in  the  lungs  : 


300  ARTIFICIAL    ANAESTHESIA. 

"1.  There  is  no  proof  whatever  of  the  occurrence  of  pulmo- 
nary obstruction  from  the  administration  in  mammals  of  anaes- 
thetic doses  of  chloroform,  sufficiently  diluted  with  air,  as  was 
the  case  in  mj'  experiments,  the  amount  of  chloroform  vapor 
in  the  air  never  exceeding  four  per  cent. 

"2.  On  the  other  hand,  there  is  decisive  proof  that  pulmonary 
obstruction  was  not  present  in  my  experiments.  Obstruction 
of  the  circulation  would  necessarily  cause  distension  of  the 
pulmonary  artery  as  well  as,  and  indeed  earlier  than,  distension 
of  the  right  heart.  The  pulmonary  artery  would  become  large 
and  tense  in  consequence  of  the  increased  peripheral  resistance 
to  the  outflow  of  blood  from  that  vessel.  Then  the  increased 
tension  would  react  upon  the  right  heart  and  cause  distension 
there  also.  But  in  my  experiments  there  was  no  distension  of 
the  pulmonary  artery  during  the  administration  of  chloroform. 
The  vessel  did  not  become  distended  ;  it  was  soft  and  compres- 
sible, and  the  tension  within  it  was  low.  It  is  quite  certain, 
then,  that  pulmonary  obstruction  could  not  have  been  the  cause 
of  the  dilatation,  even  on  the  right  side  of  the  heart. 

"3.  Even  if  pulmonary  obstruction  had  been  present — as 
was  not  the  case — such  obstruction  could  not  have  produced 
the  condition  which  I  described,  or  anything  similar  to  it. 

"I  have  on  various  occasions  purposely  brought  about  a  con- 
dition of  pulmonary  obstruction  by  mechanical  means  with  a 
view  to  studying  the  features  cf  this  condition.  This  I  did  by 
injecting  into  one  of  the  great  systemic  veins  some  particular 
substance,  e.g.  lycopodium  powder,  which  would  cause  embol- 
ism of  the  pulmonary  vessels  and  so  obstruct  the  circulation  in 
the  lungs.  When  such  a  substance  is  injected  into  the  vein,  it 
rapidly  passes  through  the  right  heart  into  the  pulmonary  ves- 
sels, speedily  causing  more  or  less  extensive  and  sudden  ob- 
struction of  the  pulmonary  circulation,  according  to  the  amount 
and  suddenness  of  the  injection." 

The  effects  resulting  from  the  plugging  of  the  minute  pul- 
monar3^  vessels  induced  in  this  way  are  very  noteworthy,  and 
illustrate  clearly  the  consequence  of  obstruction  of  the  circula- 
tion of  the  lungs.  The  pulmonary  artery  swells  up  and  be- 
comes largely  distended,  while  at  the  same  time  the  vessel  feels 


DEATHS  FROM  CHLOROFORM  AND  ETHER.    301 

hard  and  tense  to  tlie  touch ;  the  pressure  within  the  vessel  is 
greatly  elevated.  The  right  ventricle,  and  the  right  auricle 
also,  partake  in  the  condition  of  distension,  being  unable  to 
discharge  their  contents  in  the  normal  fashion  in  face  of  the 
greatlj'  augmented  resistance  in  front.  The  lungs  become  pale 
and  anaemic.  Meanwhile  it  is  important  to  observe  that  the 
left  auricle  becomes  smaller  and  collapsed-looking,  in  conse- 
quence of  the  obstacle  offered  to  the  passage  of  the  blood 
through  the  lungs.  Strong  respiratory  efforts,  with  convul- 
sions of  the  asphyxial  type  (accompanied  by  spasmodic  contrac- 
tion of  the  systemic  arteries)  supervene  in  consequence  of  the 
stoppage  of  the  respiratory  purification  of  the  blood;  the 
medullary  centres  become  violently  stimulated  by  the  venous 
character  of  the  blood.     Death  speedily  follows. 

"  It  is  unnecessary  to  enter  closely  into  a  comparison,  or  rather 
contrast,  of  the  typical  illustration  of  pulmonary  obstruction 
here  afforded,  and  the  condition  of  cardiac  dilatation  which  I 
have  described  as  occurring  under  the  influence  of  chloroform. 
It  is  obvious  that  obstruction  of  the  circulation  in  the  lungs 
produces  changes  strikingly  different  from  those  that  result 
from  the  action  of  chloroform  ;  and  that  the  hypothesis  of  pul- 
monary obstruction  may  at  once  be  dismissed  as  entirely  insuffi- 
cient and  inapplicable,  so  far  as  explanation  of  the  cardiac  dila- 
tation occurring  under  chloroform  is  concerned. 

"Seeing  that  it  is  easy  to  dispose  of  the  question  of  pulmo- 
nary obstruction  in  regard  to  the  effects  of  chloroform  upon  the 
heart,  I  shall  now  advert  briefly  to  the  possibility  of  cardiac 
dilatation  being  dependent  on  a  rapidly  falling  blood-pressure, 
as  alleged  by  Dr.  Lawrie. 

"This  is  a  matter  which  I  carefully  considered  in  my  paper, 
and  in  regard  to  which  I  was  able  to  state  definitely  that  the 
cardiac  dilatation  is  not  due  to  a  fall  of  blood-pressure.  This  is 
conclusively  proved  by  the  following  facts  :  1.  Dilatation  of  the 
heart  does  not  by  any  means  always  run  parallel  to  the  fall  of 
pressure  which  ordinarily  results  from  the  administration  of 
chloroform.  Sometimes  there  is  a  very  marked  fall  of  pressure, 
with  little  or  no  dilatation  of  the  heart,  while  at  other  times 
the  heart  begins  to  dilate  before  the  pressure  begins  to  fall. 


302  ARTIFICIAL    ANESTHESIA. 

2.  Moreover,  the  heart  in  some  instances  begins  to  dilate  during 
the  temporary  rise  of  pressure  which  at  times  precedes  the  fall. 

3.  Further,  there  may  be  distinct  dilatation  of  the  heart  with- 
out any  change  of  pressure  at  all.  4.  Lastly,  it  can  easily  be 
shown  that  a  simple  fall  of  pressure,  equal  in  amount  to  that 
which  ordinarily  occurs  under  chloroform,  induced  by  means 
which  do  not  directly  affect  the  heart — e.g.^  section  of  a  vaso- 
motor nerve,  haemorrhage,  etc. — does  not  cause  dilatation  of  the 
organ  as  chloroform  does. 

"  It  is  clear,  then,  that  the  dilatation  of  the  heart  brought 
about  by  chloroform  cannot  be  due  to  obstruction  of  the  circula- 
tion in  the  lungs,  or  to  a  fall  of  systemic  blood-pressure ;  it 
must  result  from  a  depressing  influence  exerted  by  the  anaes- 
thetic on  the  organ,  1,  directly  ;  or  2,  through  the  vagus  nerves. 

"Finally,  as  this  depressing  influence,  leading  to  dilatation, 
is  readily  manipulated  after  section  of  both  vagi,  it  is  obvious 
that  chloroform  must  act  upon  the  heart  directly.  I  cannot 
help  feeling  that  even  a  comparatively  slight  amount  of  actual 
observation  of  the  features  and  results  of  a  simple  lowering  of 
the  blood-pressure  and  of  real  pulmonary  obstruction  would 
have  prevented  Surgeon-Major  Lawrie  from  putting  forward 
and  adhering  to  such  a  hypothesis  as  I  have  here  discussed — a 
hypothesis  at  once  insufficient,  absolutely  untenable,  and  in 
conflict  with  large  and  somewhat  elementary  facts  in  the  phys- 
iology of  the  circulation." 

Respiration  After  Cliloroforni  Asphyxia. 

There  is  no  doubt  that  in  India  deaths  do  occur  (see  case  No. 
43)  from  the  administration  of  chloroform,  yet  we  know  from 
the  facts  staged  in  our  work  that  the  climate  of  that  region, 
like  our  Southern  States,  is  favorable  to  its  use  as  an  anaes- 
thetic. Recently  there  has  come  to  our  notice,  while  in  search 
for  facts  on  the  subject  of  prevention  of  deaths  from  chloro- 
form, the  following  cases  and  opinions  of  practical  surgeons, 
which  we  consider  worthy  of  most  serious  attention. 

Two  cases  of  chloroform  asphyxia  were  reported  by  Surgeon- 
Major  Bartholomew  and  Civil  Surgeon  Ahmedabad.  a.  A  pa- 
tient aged  31,  thin  and  emaciated,  had  sufi'ered  eight  years  from 


RESPIRATION    AFTER    CHLOROFORM    ASPHYXIA.        303 

vesical  calculus.  He  was  operated  on  and  the  stone,  weighing 
50ozs. ,  extracted,  when  it  was  observed  that  respiration  had 
ceased.  Ether  hj^poderniicall}'  and  the  usual  remedies  were  used 
without  effect,  and  artificial  respiration  (Sylvester  method)  con- 
tinued for  three  hours  before  the  patient  took  a  long  breath 
(the  heart  action,  though  feeble,  had  not  ceased).  Six  drachms 
of  chloroform  had  been  given. 

A  patient  aged  18  had  had  5  drachms  of  chloroform  given 
prior  to  enucleation.  After  the  operation  the  breathing  was 
observed  to  have  ceased,  and  the  patient  could  not  be  roused. 
Artificial  respiration  was  carried  on  for  one  hour,  and  on  giving 
a  galvanic  shock  the  patient  recovered  consciousness.  Drs. 
Peche}^  Phipson,  Banks,  Maconachie,  Mej'er  and  Collee,  all  of 
the  Army  of  India,  cited  instances  in  their  experience  of  pro- 
longed chloroform  asphyxia,  and  ultimate  recovery  by  artificial 
respiration  and  the  galvanic  shock.  Dr.  Meyer  stated  that 
there  was  a  danger  of  inducing  delirium  of  the  heart  by  the 
prolonged  use  of  electricity  (this  is  the  case  when  applied  too 
near  the  heart),  and  thereby  superadding  a  serious  complication 
which  might  in  itself  prove  fatal.  Frequently  patients  did  not 
breathe  for  some  time  after  artificial  respiration,  because  the 
lungs  had  had  such  a  large  quantity  of  air  thrown  in  as  to  do 
away  with  the  physiological  reflex  stimulus  to  the  respiratory 
centre. 

We  do  not  in  our  work  advise  the  use  of  hypodermics  of  mor- 
phine or  atropine  before  the  use  of  chloroform  as  an  anaesthetic, 
and  would  call  attention  to  this  case,  also,  as  the  surgeon  did 
not  employ  the  galvanic  shock,  and  did  not  keep  up  the  artifi- 
cial respiration  long  enough. 

In  a  discussion  which  took  place  in  the  Paris  Society  of  Sur- 
gery, upon  a  paper*  treating  of  the  use  of  hypodermics  of  mor- 
phine and  atropine  before  the  inhalation  of  chloroform,  the 
author  of  the  paper,  M.  Regnier,  was  led  to  try  this  method  in 
his  practice  by  the  recommendation  of  M.  Dastre,  who  reported 
favorable  results  from  its  use  in  animals,  and  of  M.  Aubert,  a 
surgeon,  who  stated  that  narcosis  and  awaking  were  facilitated 

*  L'Union  Medicale,  August  5,  1890. 


304  ARTIFICIAL    ANESTHESIA. 

by  the  injection  of  }  gr.  morphine  muriate  and  -g^  gr.  atro])ine 
sulphate  fifteen  or  twenty  minutes  before  the  operation,  and 
that  inconvenient  results  were  observed  but  rarelJ^  M.  Reg- 
nier  used  this  method  with  a  number  of  patients,  until,  unfor- 
tunately, a  fatal  accident  occurred. 

A  feeble  girl,  aged  16,  was  aifected  with  tubercular  disease  of 
the  bones  of  the  foot,  and,  as  the  lungs  presented  but  a  few 
rales  in  the  apex  of  one  side,  he  decided  to  chisel  out  the  cuboid 
bone.  Half  an  hour  before  the  operation  he  gave  a  hypodermic 
injection  of  3%  gr.  of  morphine  and  ^^5  gr.  of  atropine.  Anaes- 
thesia was  easily  induced,  and  not  more  than  from  five  to  seven 
fluid  drachms  of  chloroform  were  required  for  the  whole  opera- 
tion, which  lasted  only  a  few  minutes.  About  ten  minutes  after 
the  chloroform  had  been  removed,  and  while  the  dressings  were 
being  applied,  she  opened  her  eyes  without  speaking,  and  was 
then  carried  to  her  ward.  Three  minutes  later  news  was 
brought  that  she  had  ceased  breathing.  Upon  reaching  her 
bed  he  found  the  respirations  very  infrequent.  They  ceased 
suddenly  as  the  pulse  disappeared,  although  feeble  heart-beats 
were  still  heard.  The  pupil  then  quickly  dilated.  Protracted 
artificial  respiration  seemed,  at  the  end  of  half  an  hour,  to  excite 
spontaneous  respiration ,  but  this  soon  failed,  although  supple- 
mented by  ether  injection  and  other  methods.  Post-mortem 
examination  showed  anaemia  of  the  cerebral  hemispheres  and 
medulla  oblongata. 

Death  in  this  case  came  on  very  slowly  from  chloroform  in- 
toxication. It  was  quite  remarkable  that  life  could  be  pro- 
longed for  more  than  twenty  minutes  by  artificial  respiration. 
It  was  claimed  that  the  chloroform  must  have  been  eliminated 
slowly,  and  that  the  elimination  was  rendered  more  slow  than 
it  would  otherwise  have  been  by  the  influence  of  the  morphine 
and  atropine. 

Two  members  of  the  Society  reported  that  they  had  observed 
in  experiments  on  dogs,  that  morphine  and  atropine  given  be- 
fore chloroform,  produced  no  reflex  phenomena  at  the  begin- 
ning, but  rendered  much  more  grave  such  complications  as  ap- 
peared at  the  end.  In  some  cases  there  was  quite  protracted 
and  severe  dyspnoea.     In  dogs  thus  treated  very  little  chloro- 


CONCLUSIONS.  305 

form  was  needed  ;  in  men  more  was  required.  It  appeared  to 
be  conceded  that  the  method  was  useful  in  the  laboratorj^  but 
not  in  the  cUnic,  as  the  chances  of  intoxication  were  increased. 
Another  member  who  had  tried  the  method,  stated,  that  in 
male  patients  nothing  worthy  of  note  was  usuallj'  observed, 
while  in  female  patients  the  awaking  was  much  more  slow  than'" 
with  chloroform  alone.  He  thought  women  were  more  sensitive 
than  men  to  the  influence  of  atropine.  Out  of  five  cases  he 
had  lost  one  patient.  The  operation  was  for  nephrectomy,  and 
lasted  an  hour,  fifteen  fluid  drachms  of  chloroform  being  used. 
After  a  short  awakening  the  respiration  began  to  fail,  cyanosis 
appeared,  and  in  spite  of  all  measures,  death  occurred  in  an 
hour  and  ten  minutes. 

Conclusions. 

1.  During  the  protracted  use  of  chloroform  as  an  anaesthetic, 
the  blood  is  changed  in  character,  lowered  in  pressure,  with 
weakening  of  the  action  of  the  heart  and  changes  in  its  struc- 
ture. 

2.  Dilatation  of  the  heart  occurs  under  the  use  of  chloroform 
at  all  stages  on  both  sides  of  the  heart,  while  the  heart  muscle  is 
weakened. 

3.  Cardiac  failure  occurred  before  respiration  in  thirteen  in- 
stances out  of  forty-three  cases  of  death  from  chloroform. 

4.  The  depressing  influence  of  chloroform  on  the  heart  me- 
chanism is  not  exerted  through  the  vagus  nerves,  and  section 
of  both  vagi  does  not  obviate  the  weakening  and  dilating  influ- 
ence of  chloroform  on  the  heart. 

5.  Too  many  trifling  operations  are  performed  under  chloro- 
form ;  its  use  should  be  reserved  for  those  cases  in  which  ether, 
nitrous  oxide,  or  cocaine  will  not  produce  the  anaesthesia  desired. 

6.  Ether  deaths,  as  a  rule,  occur  in  patients  of  a  certain  class, 
usually  from  obstructed  respiration,  and  occasionally  the  heart 
will  stop  first,  as  in  two  of  the  four  cases  in  our  tables. 

7.  Watch  both  pulse  and  respiration,  both  in  chloroform  and 
ether  ;  when  the  breathing  becomes  very  rapid,  danger  is  near. 

These  changes  are  apt  to  follow  the  first  act  of  respiration. 
Chloroform  vapor  should  not  be  employed  over  four  per  cent. 


306  ARTIFICIAL    ANESTHESIA. 

NOTES  REFERRED  TO  IN  THE  TABLE. 

Note  1. 

Paralj'sis  of  pneumogastric  nerve,  the  direct  effect  of  the 
chloroform,  superinduced  by  effort  at  vomiting. 

Note  2. 

Respiration  failed  gradually,  at  one  time  stopping,  and  com- 
menced again  after  artificial  respiration. 

Note  3. 

Anaesthesia  not  complete  when  operation  commenced,  and 
heart  and  respiration  ceased. 

Note  4. 

Four  Deaths  from  the  Inhalation  of  Chloroform  in 

Reading  and  Vicinity  During  the  Past  Three 

Years.* 

On  April  8,  1890,  at  a  meeting  of  the  Berks  County  Medical 
Society,  a  paper  was  read,  entitled  "  Chloroform  Anaesthesia," 
by  Dr.  John  T.  Carpenter,  of  Pottsville,  Pa.,  which  was  published 
in  the  University  Medical  Magazine,  June,  1890.  The  drift  of 
this  paper  and  the  discussion  which  followed  was  that  chloroform, 
if  skilfully  administered,  was  a  safe  anaesthetic,  and  was  prefer- 
able to  ether  on  account  of  its  safety,  speediness  of  action,  and 
general  absence  of  any  unpleasant  sequelae.  This  discussion  dis- 
closed almost  a  unanimous  opinion  favorable  to  the  use  of  chloro- 
form as  an  anaesthetic.  One  distinguished  medical  officer  of  the 
United  States  Navy  and  two  representative  physicians  of  Phil- 
adelphia were  present,  and  they  all  displayed  a  strong  prefer- 
ence for  the  use  of  chloroform.  Only  one  physician  besides 
myself,  Dr.  W.  Murray  Weidman,  a  gentleman  of  large  sur- 

*  By  John  W.  Keiser,  M.D.,  Reading,  Pa.,  University  Medical 
Magazine,  Aiagust  6,  1895. 


TABULAE  STATEMENT  SHOWIN&  THE  "DEATHS  FROM  OHLOEOFORM  AND  ETHER  SINCE  THE  HYDERABAD  COMMISSION.' 


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NOTES  REFERRED  TO  I>'  THE  TABLE.     307 

gical   experience,   declared   himself   favorable   to  the   use    of 
ether. 

He  in  substance  said  that  he  never  had  any  experience  with 
chloroform  ;  that  he  always  used  ether,  and  that  the  exigencies 
of  railway  surgery  were  such  that  he  frequently  operated  while 
an  ordinary  workman  administered  it,  arid  that  he  never  had 
any  disastrous  results  from  its  employment.  In  this  discussion 
I  opposed  the  use  of  chloroform  with  all  the  ability  that  I  could 
command,  and  made  the  prophecy  that  if  the  opinions  I  had 
just  heard  would  be  put  into  actual  practice  they  surely  would 
result  in  an  occasional  death  from  the  use  of  chloroform,  which 
could  have  been  avoided  by  the  use  of  a  safer  anaesthetic ;  and 
it  was  not  necessary  for  me  to  wait  many  j^ears  before  the  truth 
of  this  prophecy  was  realized.  I  give  the  particulars  of  this 
meeting  as  it  reveals  the  attitude  of  the  local  profession  towards 
the  use  of  chloroform. 

In  this  community  a  large  number  of  ph.ysicians  are  very 
favorably  disposed  to  the  use  of  chloroform  ;  I  am,  neverthe- 
less, absolutely  certain  that  it  is  not  as  frequently  used  as  ether ; 
and  if  these  two  anaesthetics  were  of  equal  safety  the  deaths 
resulting  from  the  use  of  ether  would  exceed  those  from  chloro- 
form. In  a  paper  published  by  me  August,  1890,  in  the  Mag- 
azine, which  was  designed  as  a  reply  to  3Ir.  Carpenter's  paper, 
I  stated,  after  investigation,  that  I  had  learned  of  two  deaths 
from  chloroform  in  this  locality,  and  was  unable  to  discover  any 
from  ether.  Since  then  two  more  deaths  from  chloroform  have 
happened  in  this  vicinity,  making  a  total  of  four. 

With  a  view  of  impressing  upon  the  profession  the  unavoid- 
able dangers  attending  the  use  of  this  dangerous  angesthetic,  I 
will  briefly  relate  the  circumstances  of  these  last  two  deaths. 
About  three  years  ago  a  competent  physician  of  this  city,  now 
deceased,  went  to  a  neighboring  village  to  operate  on  a  multiple 
stricture  of  the  urethra  in  a  middle-aged  gentleman.  After  the 
chloroform  was  inhaled  a  few  moments  the  patient,  without  a 
moment's  warning,  suddenly  died.  The  physician  who  gave 
the  anaesthetic  admitted  to  me  in  private  conversation  that  the 
only  cause  of  death  in  this  case  was  chloroform,  and  expressed 
regret  that  he  had  not  used  a  safer  anaesthetic. 


308  ARTIFICIAL    ANAESTHESIA. 

About  one  month  ago  a  girl  of  16  applied  to  the  Reading 
dispensaiy  for  the  removal  of  a  small  but  disfiguring  growth 
upon  one  of  her  eyelids.  The  two  competent  phj^sicians  en- 
deavored to  persuade  her  to  submit  to  the  operation  without  an 
anaesthetic,  but  she  insisted  upon  having  it.  According  to  a 
newspaper  report,  made  by  the  attending  physicians,  about 
fifteen  drops  of  chloroform  were  placed  on  a  towel,  and  after 
taking  several  inhalations  she  sprang  from  the  table.  She  was 
again  persuaded  to  get  on  the  table,  and  the  instant  the  inhala- 
tions were  recommenced  she  died.  The  coroner's  jury  rendered 
the  following  verdict:    "Death   was  caused  by   heart-failure 

while  being  put  under  the  use  of  chloroform We  agree 

that  the  chloroform  was  administered  in  the  usual  professional 
manner. ' '  The  physicians  in  this  case  contended  that  the  girl 
died  from  fright,  and  not  from  the  anaesthetic;  but  I  think 
that  the  verdict  was  a  just  one,  and  that  fright  was  insufl&cient 
to  account  for  death.  If  it  was  a  factor  in  the  death  of  this 
unfortunate  girl  it  was  only  possible  in  conjunction  with  the 
paralyzing  influence  of  chloroform. 

I  believe  that  if  all  deaths  from  chloroform  were  published 
in  the  medical  journals  the  number  would  be  enormous,  and  the 
publicity  would  compel  the  abandonment  of  chloroform  as  an 
anaesthetic,  save  in  a  few  cases  in  which  it  would  be  specially 
indicated. 

Note  5. 

' '  In  the  case  given  there  is  little  doubt  that  a  valuable  life 
might  have  been  spared.  A  youth,  aged  15,  required  eleven 
teeth  to  be  taken  out  to  qualify  him  for  admission  into  the 
Royal  Navy.  An  appointment  was  made  by  a  dentist  with  the 
youth's  own  medical  man  to  give  chloroform.  We  do  not  wish 
to  pillory  this  gentleman,  with  whom  we  deeply  sympathize  for 
the  terrible  disaster  with  which  he  is  associated  ;  we  are  aware 
that  very  many  practitioners  adopt  the  plan  he  resorted  to  and 
recognize  it  as  a  routine  procedure  in  dental  operations.  We 
must,  however,  most  emphatically  denounce  it  as  a  dangerous 
and  undesirable  one.  Chloroform  was  administered  with  a 
towel — a  method  which  easily  induces  an  overdose  of  the  anaes- 


NOTES  REFERRED  TO  IN  THE  TABLE.     309 

thetic — and  the  pulse  was  kept  under  observation.  We  read 
nothing  of  the  respiration  or  the  pupil,  though  doubtless  they, 
too,  were  kept  under  observation.  The  dentist  removed  one 
tooth,  and  finding  the  second  somewhat  difficult  some  delay 
arose,  during  which  the  boy  partly  came  round.  The  chloro- 
form was  readministered  and  the  remaining  teeth  were  re- 
moved. Then  the  patient  died.  In  a  report  which  is  before 
us  we  read  that  the  medical  man  in  his  evidence  said:  'Turn- 
ing round  again,  he  noticed  a  change  in  the  patient's  condition.' 
It  is  significant  how  often  '  going  wrong '  occurs  when  the  back 
is  turned.  The  necropsy — performed  by  an  independent  med- 
ical man — revealed,  we  are  informed,  the  startling  fact  that  on 
examination  of  this  boy,  who  is  described  as  being  in  '  perfect 
health '  and  as  having  been  passed  for  the  Royal  Navy  at  head- 
quarters except  as  regarded  his  teeth,  that  his  lungs  were  in 
such  a  condition  that  '  the  boy  could  not  have  lived  above  two 
years.'  Surely  no  lesion  so  serious  could  have  escaped  the 
examination  at  headquarters,  and  that  of  the  medical  man  who 
expressly  states  he  scrutinized  the  lad  before  giving  him  the 
chloroform.  The  posture  of  the  patient  is  not  mentioned ; 
probably  the  boy  was  in  the  dentist's  chair — a  position  unsuited 
for  the  administration  of  chloroform." — London  Lancet,  March 
12,  1893. 

Note  6. 

Deaths  from  Ether. 

Our  friends  think  we  have  in  our  previous  editions  not  given 
so  much  prominence  to  the  deaths  from  ether  as  to  those  from 
chloroform,  still  we  can  state  truthfully  that  our  work  will  be 
found  to  contain  the  whole  number  of  deaths  from  all  anaes- 
thetics as  far  as  we  have  been  able  to  collect  them,  sparing  no 
time  nor  money  in  the  effort  to  do  so,  and  these  deaths  were 
reported  in  full  not  only  before  the  meeting  of  the  British 
Medical  Association  in  1893-4,  but  also  published  to  the  med- 
ical world,  and  in  this  edition  we  publish  some  additional 
deaths. 


310  ARTIFICIAL    ANESTHESIA. 

Official  Statement  from  the  Paris  Edition  of  the  New 

York  Herald,  March  27,  1893,  by  His  Physicians, 

AS  TO  the  Death  of  Colonel  E.  F.  Shepard 

FROM  Ether. 

At  the  request  of  Mr.  Chauncey  M,  Depew  and  the  members 
of  the  Shepard  family,  Drs.  McBurney  and  McLane  have  pub- 
lished the  following  statement  : 

"We  met  at  Colonel  Shepard' s  house  for  the  purpose  of 
making  an  exploration,  under  ether,  on  the  bladder,  and  pro- 
posed, if  practicable,  to  remove  the  stone  which  it  contained. 
The  presence  of  the  stone  was  determined  by  two  careful  exam- 
inations on  February  24th  and  March  9th.  These  examinations, 
which  were  made  without  the  use  of  an  anaesthetic,  gave  the  pa- 
tient some  pain.  Between  Feburary  24th  and  March  24th  several 
examinations  of  the  urine  were  made,  but  no  evidence  of  any 
organic  disease  of  the  kidneys  was  found.  The  heart  and  lungs 
were  healthy,  and,  after  a  careful  examination,  no  disease,  such 
as  might  interfere  with  the  proper  performance  of  the  opera- 
tion, was  discovered.  The  operation  was  postponed  at  Colonel 
Shepard's  request  until  March  24th.  We  especially  instructed 
him  to  eat  very  lightly  on  the  day  of  the  operation  and  to  take 
no  food  afterwards. 

.  Before  the  Operation. 

"We  found  Colonel  Shepard  in  his  study,  apparently  in  good 
spirits,  but  he  felt  a  little  nervous  about  the  operation.  He 
removed  his  clothes,  wrapped  himself  in  a  dressing-gown, 
looked  about  the  room  and  at  the  seemingly  elaborate  prepara- 
tions and  expressed  surprise  at  their  detail.  He  was  told  that 
they  related  chiefly  to  surgical  cleanliness  and  were  no  greater 
than  would  be  made  at  a  good  hospital, 

"At  a  quarter  to  one  o'clock  the  administration  of  ether  was 
commenced,  it  having  first  been  explained  to  him  that  he  was 
to  take  full  inspirations  and  not  to  offer  any  resistance,  in  order 
to  come  more  rapidly  under  the  influence  of  the  anaesthetic. 
For  a  few  minutes  he  inhaled  the  ether  uncommonly  well, 
breathing  full  and  freely.     His  color  then  changed  somewhat, 


NOTES  REFERRED  TO  IN  THE  TABLE.      311 

he  was  apparent!}'  nauseated  and  in  another  moment  vomited. 
After  that  his  color  was  better,  but  his  respiration  was  not  sat- 
isfactorj'  nor  was  his  pulse.  The  further  administration  of  the 
anaesthetic  was  therefore  discontinued,  but  as  yet  not  enough 
ether  had  been  given  to  continue  the  proposed  operation. 

"All  our  efforts  were  now  directed  to  securing  proper  respira- 
tory action.  As  usual  in  cases  where  the  respiration  is  not 
perfectly  satisfactory,  the  breathing  continuing  very  labored, 
an  examination  was  made  of  the  larnyx  to  discover  whether 
possibly  a  particle  of  food  had  lodged  in  it,  but  this  was  proved 
not  to  be  the  case. 

"  Extreme  Measures  Resorted  to. — The  patient's  condi- 
tion was  now  so  alarming  as  to  call  for  extreme  measures,  and, 
in  the  hope  that  the  symptoms  were  due  to  the  presence  in  the 
windpipe  of  vomit  material,  accidentally  inhaled,  the  operation 
of  tracheotomy  was  performed.  No  foreign  material  was  found. 
We  even  passed  a  rubber  tube  down  the  windpipe  into  the 
bronchial  tubes,  making  use  of  a  powerful  aspirating  syringe, 
without  discovering  the  presence  of  anything  but  bloody  mucus. 

"In  the  meantime  several  careful  examinations  were  made 
of  the  lungs,  and  sounds  heard  indicated  oedema  of  these  organs. 
Oxygen  had  been  previously  sent  for,  and  under  its  influence 
the  patient  slightly  revived.  Artificial  respiration  and  every 
other  means  that  might  possibly  give  relief  were  resorted  to. 
From  this  time  onwards  the  patient's  breathing  was  even  more 
embarrassed,  but  still  artificial  respiration  was  continuously  kept 
up,  although  the  pulse  became  steadily  more  feeble.  Colonel 
Shepard  sank  rapidly  into  unconsciousness  in  spite  of  all  our 
efforts,  and  died  at  ten  minutes  past  four. 

"The  Cause  of  Death. — Our  opinion  is  that  Colonel 
Shepard  died  from  sudden  oedema  (congestion  of  the  lungs) 
following  upon  the  administration  of  ether,  but  primarily  due 
to  some  cause  unknown  to  us. 

' '  James  W.  McLane,  M.  D.  , 
(Signed)  ' '  Charles  McBurney,  M. D.  ' ' 

Ed,  Note. — The  unfortunate  part  of  this  case  is  that  no 
post-mortem  verified  the  cause  of  death. 


312  ARTIFICIAL    ANAESTHESIA. 

The  Relative  Mortality  of  Ether  and  Chloroform 
as  Anaesthetics.* 

"  In  preparing  statistics  upon  the  subject  of  ether  and  chlo- 
roform as  anaesthetics  we  have  endeavored  to  adhere  closely  to 
certain  principles  of  criticism  which  we  reluctantly  adopted  as 
absolutely  necessary  in  order  to  reduce  the  evidence  before  us  to 
coherence.  Data  of  varying  degrees  of  merit,  and  obtained 
under  such  different  conditions  that  it  is  the  greatest  careless- 
ness to  range  them  together  as  facts  of  equal  weight,  are  never- 
theless commonly  found  side  by  side.  From  such  statistics  we 
could  not  draw  any  definite  conclusions.  Nay,  the  conditions 
are  ignored  which  we  proposed  to  ourselves  as  the  ultimate  test 
of  the  value  of  any  series  of  data.  Are  there,  we  asked  our- 
selves, any  observations  recorded  that  show  that  ether  and  chlo- 
roform have  been  fairly  tried  together  upon  that  common 
ground  on  which  both  may  enter  as  anaesthetics  and  display 
their  peculiar  powers  upon  cases  regularly  selected  with  care 
and  judgment?  Pursuing  this  subject,  we  have  been  on  our 
guard  against  any  bias  in  ourselves  and  have  carefully  searched 
for  it  in  the  writings  of  others. 

"The  number  of  papers  to  be  examined  is  astonishingly 
great.  Most  of  them,  we  are  sorry  to  say,  are  liable  to  the 
suspicion  of  partiality.  Among  those  of  doubtful  authority, 
from  our  own  point  of  view,  which,  it  must  be  remembered,  is 
purely  critical,  are  the  following :  The  experimental ;  those 
recounting  individual  experiences  with  ether  alone  or  with 
chloroform  alone  ;  those  that  assume  that  the  use  of  chloroform 
ought  to  be  entirely  abandoned ;  the  controversial  and  polemic, 
of  which  unfortunately  there  are  some.  Secondly,  we  have 
noted  as  instances  of  that  frame  of  mind  which  is  unsuitable 
for  fair  judgment  such  statements  as  Surgeon-Major  Lawrie's, 
that  '  the  most  important  result  of  the  labors  of  the  Hyderabad 
Commission  has  undoubtedly  been  to  establish  the  proof  that 
chloroform  has  never,  under  any  circumstances  whatever,  a 
direct  action  upon  the  human  heart ;'  or  M,  Julliard's  confes- 

•-•■  Editorial  from  The  Medical  News,  Philadelphia,  October  1,  1892, 
by  Dr.  George  M.  Gould. 


RELATIVE  MORTALITY  OF  ETHER  AND  CHLOROFORM.  313 

sion  that  for  ether  he  has  long  been  '  tin  partisan  convaincu ;' 
or  again,  his  saying,  too  loosely  we  feel,  that  'Prof  Tripier 
has  administered  ether  without  accident  6500  times,  while  on 
the  other  hand  he  had  a  case  of  death  snr  un  nombre  infiniment 
mohulre  ch  chhroformisation.' 

"It  is  enough  to  observe  here  that  by  following  any  party  or 
school  we  cannot  arrive  at  the  truth.  In  our  own  j udgment,  it  is 
assuredly  unfortunate  that  men  will  use  one  anaesthetic  exclu- 
sively, for  some  cases  are  fit  for  chloroform,  others  for  ether, 
others  again  for  nitrous  oxide  gas,  still  others,  perhaps,  for  the 
A.  C.  E.  mixture. 

"Naturally,  we  have  not  found  many  statistics  that  are  free 
from  the  faults  that  we  have  either  pointed  out  or  hinted  at. 
Indeed,  we  know  but  one  that  is  accurate,  and  has  besides  the 
merits  we  required.  Such  statistics,  we  felt  bound,  must  show 
observation  of  scientific  accuracy,  taken  during  a  considerable 
time,  under  uniform  conditions,  by  men  of  approved  ability  and 
knowledge  entirely  interested  in  a  fair  trial  of  ether  and  chloro- 
form, using  neither  one  nor  the  other  exclusively,  but  both 
alike  and  as  nearly  as  possible  an  equal  number  of  times  ;  with 
registrations  made  at  the  time  of  the  operation,  of  the  number 
of  cases,  with  the  deaths  and  accompanying  circumstances.  By 
means  of  these  statistics,  and  these  alone,  may  we  hope  to 
arrive  at  a  final  judgment  on  the  controverted  claims  of  ether 
and  chloroform.  We  append  a  table  of  these  desirable  data. 
It  is  compiled  immediately  from  the  St.  Bartholomew's  Hos- 
pital Reports.     It  includes  all  the  observations  made. 

"It  must  be  admitted  that  these  results  are  by  no  means 
favorable  to  chloroform,  yet  we  do  not  go  so  far  as  to  say,  with 
M.  Julliard,  that  we  must  show  these  statistics  to  be  inexact, 
or  renounce  chloroform.  We  see  that  the  use  of  chloroform 
has  increased  with  moderate  fluctuations,  reaching  a  maximum 
in  1890,  and  a  preponderance  over  ether  in  that  year  of  727 
cases,  with  one  death  for  each  anaesthetic.  It  is  evident,  then, 
that  the  surgeons  had  sufficient  confidence  in  chloroform  to 
continue  its  use— a  fact  in  its  favor.  Whether  this- confidence 
is  deserved  we  may  judge  by  an  examination  of  the  circum- 
stances attending  the  deaths.     In  the  table  we  have  noted  the 

21 


314 


ARTIFICIAL    ANESTHESIA. 


cases  of  syncope  ;  these  may  be  left  to  speak  for  themselves. 
Of  the  remaining  deaths,  we  maj^  ascribe  two  to  asphyxia. 
The  others,  we  think,  were  highly  probable  with  any  anaes- 


Number  of  Cases. 

Deaths. 

vA 

-o  « 

V.'x 

Remarks  on  the  Cases 

^ 

o^ 

g 

ciO 

Pertaining  to  Chlo- 

=2 

o 

JU   02 

roform. 

^' 

o 
o 

o 

o 

o3 

^ 

^ 

5!^ 

5 

a^zi 

!>H 

W 

•^ 

H 

187o 

617 

120 

764 

None 

None 

None 

1876 

670 

28 

1004 

" 

" 

<i 

1877 

699 

28 

1123 

(( 

(I 

(( 

1878 

794 

15 

1009 

1 

1 

(( 

Syncope  after  opera- 
tion. 

1879 

975 

23 

984 

1 

None 

ii 

Syncope  after  opera- 
tion. 

1880 

1055 

43 

1304 

None 

1 

(t 

1881 

1072 

85 

1209 

1 

None 

it 

Syncope  before  opera- 
tion. 

1882 

1349 

337 

1076 

2 

« 

1 

1883 

1421 

566 

1156 

2 

(i 

None 

1884 

1244 

1016 

704 

None 

« 

(( 

1885 

1331 

1118 

386 

a 

n 

(( 

1886 

1425 

1109 

567 

1 

« 

(( 

Syncope  before  opera- 
tion. 

1887 

1702 

1197 

662 

1 

« 

« 

Syncope  after  opera- 
tion. 

1888 

1711 

1003 

349 

1 

11 

« 

1889 

1601 

810 

509 

2 

(I 

(< 

Syncope. 

1890 

1860 

998 

135 

1 

1 

Syncope. 

Total... 

19,526 

8491 

12,941 

13 

3 

1 

Propor- 

tion of 

deaths, 

1875  to 

1890 

1 :  1502 

1 :  2830 

1 :  12,941 

thetic.  Thus  we  have  nine  deaths  out  of  thirteen,  which  suf- 
ficiently enforce  the  peculiar  dangers  of  chloroform.  With 
these  facts  before  us  we  cannot  feel  any  great  degree  of  confi- 
dence in  that  anaesthetic.  If,  on  the  other  hand,  we  look  at 
the  circumstances  attending  the  three  deaths  under  ether,  we 


RELATIVE  MORTALITY  OF  ETHER  AND  CHLOROFORM.  315 

shall  see  that  they  were  almost  inevitable.  The  report  of  the 
first  is  as  follows  : 

"  1.  A  man,  aged  forty-seven,  died  when  under  the  influence 
of  ether.  He  was  suffering  from  intestinal  obstruction,  for 
which  lumbar  colotomy  was  undertaken.  In  the  morning  he 
had  had  a  severe  attack  of  dyspnoea.  He  was  in  a  state  of  pro- 
found collapse  at  the  time  of  the  operation :  his  belly  was 
tumid,  his  respiration  shallow,  and  his  jiulse  feeble.  He 
vomited  frequently,  and  after  inhaling  ether  for  ten  minutes 
became  livid  and  never  again  rallied. 

"2.  A  man.  aged  sixty-one.  suffering  from  strangulated 
inguinal  hernia,  died  under  the  influence  of  ether.  He  had 
been  delirious  the  previous  night ;  his  pulse  was  irregular  and 
feeble,  and  he  had  constant  vomiting.  During  the  operation 
the  pulse  became  imperceptible,  and  finally  respiration  ceased. 
x\t  the  necropsy  the  heart-substance  was  found  slightly  fatty ; 
the  cavities  were  nearly  empty,  containing  no  clots.  The  lungs 
were  emphysematous ;  all  the  posterior  parts  were  engorged 
with  blood. 

"3.  A  man.  aged  fifty-six.  died  under  the  influence  of  ether. 
He  was  a  drunkard  and  had  sustained  a  fracture  of  the  tibia 
and  fibula.  After  suffering  from  delirium  tremens  for  ten  days, 
ether  was  administered  in  order  to  reset  the  broken  bones. 
This  was  satisfactorily  done,  and  three  minutes  after  the  cessa- 
tion of  the  administration  of  ether  the  heart  suddenly  ceased 
beating,  then  respiration  stopped,  and  the  patient  died.  A 
post-mortem  examination  showed  the  lungs  much  engorged,  a 
flabby  heart,  and  a  fatty  liver. 

"We  have  given  great  prominence  to  these  statistics  on  ac- 
count of  the  merit  they  possess  and  the  excellent  model  they 
furnish.     We  cannot  be  too  grateful  for  them. 

"Next  to  the  statistics  of  St.  Bartholomew,  we  selected 
others  from  the  Proceedings  of  the  German  Chirurgical  Society, 
Berlin,  April.  1S91.  They  are  inferior  in  many  particulars, 
and  they  furnish  very  few  administrations  of  ether.  The  data 
were  supplied  by  66  colleagues,  chiefly  German,  besides  3  Aus- 
trian. 3  Russian.  2  Swedish.  1  each  from  Holland  and  Belgium. 


316  ARTIFICIAL    ANAESTHESIA. 

Bardeleben,  from  the  Charite,  1878-90,  sends  statistics  of  over 
12,000  administrations  of  chloroform  with  7  deaths.  In  addi- 
tion were  reported : 

Cases.       Deaths.  Asphyxia. 


Chloroform, 

22,656 

6 

71 

Ether  alone, 

470 

0 

0 

Ether  and  chloroform, 

1,055 

0 

5 

6  76 

"There  was  thus  one  death  in  3776  administrations  of  chlo- 
roform. The  duration  of  the  narcosis  in  2732  cases  was  one 
hour;  in  278  a  longer  time,  sometimes  from  150  to  155  min- 
utes. In  the  Charite,  in  the  last  six  years,  1  c.cm.  of  chloro- 
form was  used  per  minute  during  the  narcosis.  The  greatest 
amounts  used  during  an  operation  ranged  from  150  c.cm.  to  180 
grams." 

We  have  not  space  for  all  the  tables  of  Dr.  Gould,  but  we  give 
his  conclusions  in  regard  to  the  relative  mortality  from  ether 
and  chloroform  as  follows  : 

"From  1875  to  1890,  inclusive,  in  the  St.  Bartholomew  Hos- 
pital, anaesthesia  was  produced  19,526  times  by  chloroform, 
8491  times  by  ether,  and  12,941  times  by  ether  preceded  by 
nitrous  oxide.  The  number  of  deaths  were  respectively  13,  3, 
1,  giving  the  mortality  of  chloroform  as  1  in  1502,  ether  as  1 
in  2830,  and  ether  preceded  by  nitrous  oxide  as  1  in  12,941. 

"The  most  recent  and  probably  the  best  is  the  table  prepared 
by  Dr.  Gould,  based  upon  that  published  by  Julliard,  who  in 
turn  used  that  of  Compte  as  a  foundation.  In  this  table  there 
are  included  638,461  administrations  of  chloroform,  with  a  total 
of  170  deaths;  300,157  administrations  of  ether,  with  a  total  of 
18  deaths,  giving  a  mortality  of  chloroform  anaesthesia  as  1  in 
3749  and  ether  anaesthesia  as  1  in  16,675." 

"  If  we  add  Dr.  Eabatz's  experience  with  ether,  150,000  ad- 
ministrations without  a  death,  we  have  the  weightiest  evidence 
yet  adduced  by  a  single  expert  of  the  superior  safety  of  anaes- 
thesia with  ether." 


HOSPITAL    RECORDS. 


317 


Hospital  Records. 

We  notice  with  regret  that  some  of  our  hospitals  are  not 
careful  enough  in  the  record  of  their  cases  of  anaesthesia. 

The  following  are  two  forms  of  record,  one  more  brief  than 
the  other. 

First,  the  examination  of  the  urine,  placed  on  Card  No.  1. 

No.  1. 

Date 

Name Ward 


Urine. 

Quantity Color 

Reaction Sp.  G-r 

Albumen Sugar Urea. 

Remarks , 


To  be  sent  up  with  the  patient  before  using  the  anaesthetic, 
and  Card  No.  2, 


Name 

V 

Wd 

Date. 

Qt. 

24  hrs. 

Color. 

Sp.  Gr. 

React. 

Alb. 

Sug. 

Urea. 

Remarks. 

Is  hung  to  his  bedstead  for  daily  record. 


Urinalysis. 
Ward.  Bed. 


No.  Name, 

charge. 

Quantity  in  24  hours.  Color 

Gr.  Reaction.  H.N.O3. 

Boiling— methods  of  Tanret,  FehHng,  Trommer,  Heller ;  mi- 
croscope by  the  pathologist,  with  remarks. 


Physician  in 
Sediment.  Sp. 


818  ARTIFICIAL    ANESTHESIA. 

Record. 

No.  Age.  Date.  Ward.  Bed. 

Character  and  kind  of  operation  to  be  done. 

Examination  of  the  heart,  lungs,  urine,  temperature  before 
operating. 

Pulse  before  and  after  operation,  during  and  after  anaesthetic 
is  used. 

Quantity  employed,        oz. ,        drachms,        drops. 

Complications  and  treatment. 

Recovery. 

Death — how  soon  after. 

Report  of  Autopsy. 

No.  Name.  Date  of  death.  Nationality.  Height. 
Weight.  General  appearances  of  rigor  mortis.  Head.  Tho- 
rax. Left  pleura.  Left  lung.  Right  pleura.  Right  lung. 
Pericardium.  Heart.  Abdomen.  Liver.  Spleen.  Left 
kidney.      Right  kidney.      Intestines.      Stomach.      Pancreas. 

Bladder. 

Remarks. 

Pathological  diagnosis. 

Clinical  diagnosis. 

Date  and  name  of  pathologist. 

An  Abstract  of  the  Deadly  After-Effects  of 
Cliloroforni.^ 

By  Dr.  C.  Thiem  and  Dr.  P.  Fischer. 

The  knowledge  that  death  can  happen  during  chloroforming 
by  paralysis  of  heart  and  respiratory  organs  (aux  100,000  Nar- 
kosen  rechnet  man  100-150  Todesfalle)  is  general,  but  the 
knowledge  about  the  deadly  after-effects  is  of  more  recent 
date,  and  less  generally  known. 

There  is  no  doubt,  according  to  our  research,  that  the  elimi- 
nation of  chloroform  or  of  its  decomposing  products  (Zerset- 

*  Uber  totliche  Nachwirkung  des  Chloroforms  (Deutsche  Medi- 
zinal-Zeitung,  Berlin,  1889,  x.,  1111-1114).  Translation  by  Dr.  J.  M. 
Lamb,  Washington,  D.  C. 


DEADLY  AFTER-EFFECTS    OF    CHLOROFORM.        319 

zungsprodukte)  does  not  happen  as  quickly  as  was  supposed 
(two  days),  but  that,  for  instance,  elimination  through  the 
urine  has  happened  twelve  daj^s  after  chloroforming. 

As  long  as  this  product  is  not  eliminated,  the  effects  of  chlo- 
roform are  to  be  feared. 

The  decision  of  Volkman  goes  to  show  that,  especially  in  the 
cases  of  death  of  children,  supposed  to  be  due  to  shock  or 
"karbolintoxication"  after  operation,  it  is  due  to  the  chloro- 
form administered. 

A  case  of  death  four  days  after  operation  is  quoted.  It  was 
circulated  at  the  time  that  this  case  died  during  the  operation. 

Their  aim  was  (in  this  research)  to  ascertain  how,  and  how 
long  the  chloroform  and  its  ' '  zersetzungsprodukte  "  decompos- 
ing products  can  be  found  in  the  exudations  of  the  body,  and 
especially  in  the  urine. 

1.  Hegar  and  Kaltenbach  proved,  in  1S69,  that  the  capa- 
bility of  reduction  of  the  chloroform  in  the  urine  does  not  de- 
pend upon  glycosuria,  but  that  it  was  unchanged  chloroform  in 
the  urine. 

2.  Zweifel  proved  chloroform  to  be  present  in  the  urine  of  the 
new-born,  to  whose  mother  the  chloroform  had  been  administered. 

3.  Kast  shares  the  doubts  of  Zweifel,  whether  or  not  the  re- 
ducing substance  in  the  urine  of  the  chloroformed  subject  is 
unchanged  chloroform,  particularly  as  he  has  tried  the  "Iso- 
nitricreaktion  "  (the  most  delicate  reagent  for  the  detection  of 
chloroform)  in  a  number  of  urinary  examinations,  with  but 
negative  results. 

They  go  on  to  give  some  of  their  researches  concerning  the 
detection  of  presence  of  chloroform,  methods,  reagents,  etc. 

Give  experiments  on  animals— rabbits,  dogs,  etc. — and  mode 
of  examination. 

The  summary  goes  to  show  the  positive  conclusion  that  pure 
chloroform  is  present  in  the  urine,  as  all  the  experiments  proved, 
on  man  as  well  as  on  the  lower  animals. 

G-ives  directions  for  conducting  the  examinations,  closed  re- 
ceptacles, etc.,  and  attributes  the  failure  to  find  it,  by  some 
researchers,  to  the  fact  that  the  urine  is  left  exposed  in  vessels 
for  a  varying  length  of  time. 


320  ARTlf'ICIAL    ANAESTHESIA. 

The  Kesults  as  Observed  in  the  Tissues.— Fatty  de- 
generation is  most  common  where  death  is  the  result  of  chloro- 
form. Liver  first  in  order  of  afl"ection,  the  heart,  the  other 
organs  variously.  It  is  a  fatty  degeneration,  and  7iot  a  fatty 
infiltration. 

Ethel  shows  same  results,  though  not  so  marked. 

Some  Experiments. 

Cases  1  and  2. — Two  rabbits  ;  chloroformed  two  days  in  suc- 
cession, and  killed  on  the  third  day  by  chloroform. 

Case  3. — One  rabbit ;  chloroformed  three  days  in  succession  ; 
first  two  days,  three  hours  long  ;  third  day,  two  hours  long. 

Died  eight  hours  after  last  narcosis. 

Case  4. — One  young  dog;  three  days  in  succession,  two 
hours  each  day;  narcosis.  Fourth  day,  chloroformed  three 
hours.  Died  forty-eight  hours  later  (the  first  twenty-four  hours 
after  last  administration  he  appeared  well  and  cheerful). 

Case  5. — A  large,  strong  "  zughound;"  five  hours,  successive 
deep  narcosis. 

Died  next  day  after  one  and  a  half  hours'  administration. 

Sections  of  the  first  three  (cases  1,  2,  3)  showed  large,  fatty 
infiltration,  a  granular  cloudiness,  besides  the  beginning  of  fatty 
degeneration  of  liver  cells  ;  heart  muscle  granular,  opaque,  and 
beginning  to  show  fatty  degeneration. 

Rest  of  organs  unchanged. 

Cases  6  and  7. — Dogs.  Fatty  degeneration  more  marked, 
especially  in  the  last  case.  Liver  positively  white.  "DieLe- 
bern  sahen  geradeso  weiss  wie  die  genudelter  Ganse  aus."  Kid- 
ney opaque  and  granular  appearance  ;  heart,  same  appearance, 
but  less  marked.  Stomach  granular  and  opaque  appearance. 
Other  organs  unchanged.  These  examinations  proved  the  liver 
to  be  the  first  organ  affected. 

He  now  gives  the  following  case:  "Totliche  Nachwirkung 
des  Chloroforms  bei  einem  36,  jahrigen  Manne  4,  Tage  nach 
der  Narkose." 

Few  analogous  cases,  at  least  in  literature.  Quotes  Herff. 
(Sitz.-Ber.  der  D.  Med.-Ztg.,  82,  1889). 

Miillerknecht  Lohde,  age  63,  strong  man,  muscular,  and  up 


GENERAL  CONDITION  ON  DAY  OF  OPERATION.   321 

to  27th  September,  18S9,  7  P.  M.,  easily  carried  heavy  weights, 
a  sure  indication  that  he  was  not  troubled  with  any  fattj'-  de- 
generation of  heart.  His  employer  gave  the  information  that 
he  was  an  industrious  and  reliable  man,  that  he  drank  but  mod- 
erately, and  was  never  known  to  be  drunk. 

At  the  above  described  time  he  suffered  a  fracture  of  the  left 
patella,  "  Splitterbruch  der  linken  Kniescheibe "  (splintered 
fracture  of  the  patella),  while  carrying  a  hundred  weight  of 
flour.  He  fell  on  a  stone  step,  but  got  up  and  carried  his  load 
some  distance  when  he  broke  down. 

The  same  evening  a  temporary  bandage  was  applied,  and  he 
was  removed  next  morning  to  our  institution  (9  a.m.). 

We  found  a  large  hemorrhage  in  the  knee-joint ;  entire  ex- 
tremit}^  very  much  swollen,  and  intermuscular  haemorrhage. 
Considerable  separation  of  fragments.  Pulse  and  temperature 
normal.     Pulse,  for  such  a  constitution,  somewhat  soft. 

After  injection  of  almost  two  centigrams  of  morphia,  he  was 
chloroformed  with  Esmarch's  inhaler  with  "officinal  chloro- 
form. ' '  We  did  not  use  the  "  chloral  chloroform, "  as  we  find  no 
advantage  in  its  use ;  and,  furthermore,  a  recent  death  occurred 
by  its  use  at  the  "  Charite. " 

Patient  became  much  excited,  and  resented  the  application 
for  half  an  hour,  during  which  time  he  had  strong  muscular 
contractions.  Chloroform  was  repeatedly  applied,  but  had  no 
effect,  and  in  the  space  of  seventy  minutes  we  must  have  used 
150  grams  of  chloroform. 

The  operation  consisted  in  freeing  the  hgemorrhage  by  an  in- 
cision ;  of  the  adaptation  of  the  fracture  and  suture  of  the  perios- 
teum ;  bandage  of  iodoform  gauze  and  sterilized  cotton ;  care- 
ful packing  of  the  entire  limb,  and  plaster  bandage. 

General  Condition  on  Day  of  Operation. 

Temperature,  37.6;  pulse,  90,  not  over  strong;  delirium  at 
night. 

Afternoon  of  next  day  much  pain  in  the  whole  leg. 

In  the  morning,  temperature  37.6 ;  in  the  evening,  38.12; 
pulse,  90  and  100. 


322  ARTIFICIAL    ANAESTHESIA. 

As  the  plaster  bandage  was  not  tight,  it  was  not  removed 
until  next  daj^     Patient  continues  to  complain  of  pain. 

Second  night,  delirious.  Leg  and  wound  give  same  appear- 
ance as  at  the  operation.  Leg  a  little  more  swollen,  and  shows 
the  well-known  ecchyraosis.  Splints  were  now  substituted.  Is 
now  delirious  during  day.  Temperature,  38.0.  Pulse,  96 ; 
weak,  but  plainly  perceptible.  In  the  evening  a  marked  change, 
with  weakness,  and  with  stronger  delirium.  From  the  second 
day,  patient  received  wine,  and  cognac  and  egg  (Stockesche 
mixture),  tablespoonful  every  hour.  In  the  evening,  tempera- 
ture 38.3;  pulse  120,  wiry  and  small.  After  an  injection  of 
ether  camphor  it  was  better. 

Entire  night  received  wine  and  the  Stockesche  mixture. 

Next  morning,  pulse  barely  perceptible  at  120  ;  temperature, 
37.2.  Used  injection  of  ether  and  other  stimulants,  and  condi- 
tion becomes  more  encouraging. 

Toward  evening,  patient  pulseless.  After  an  infusion  of  1000 
grms.  of  "  Kochsalzlosung  mit  Zuckerzusatz  "  (common  salt  so- 
lution with  sugar)  injected  in  forearm,  the  pulse  appears 
plainly,  and  patient  more  satisfied  and  cheerful.  Directly  after 
the  infusion,  rapid  and  deep  respiration  ,  after  an  hour,  sterto- 
rous. Pulse  loses  again,  and  patient  dies  at  10  p.m.  Cardia2 
failure. 

P.M. — Shows  exquisite  fatty  liver,  with  fatty  infiltration  and 
fatty  degeneration  of  liver  cells.  Liver  much  enlarged  in  all 
lobes.  Waxy  consistence  and  no  evidence  of  inflammatory 
hypertrophy  as  appears  in  first  stages  of  cirrhosis.  Kidney, 
stomach  and  intestine  normal.  The  urine  from  the  cadaver, 
as  also  that  examined  during  life,  shows,  on  boihng  with  Fehl- 
ing's  solution,  a  deep  black  precipitate,  no  indication  of  sugar, 
but  no  "isonitril  reaction." 

Most  marked  appearance  in  the  heart.  Muscles  almost  en- 
tirely fatty  and  cross  striation  barely  perceptible.  After  using 
acetic  acid  the  muscular  fibres  (die  muskehchlduclie)  remain  filled 
with  highly  refractive  drops  of  fat.  This  case  shows  without 
doubt  fatty  degeneration  caused  by  chloroform.  Even  if  the 
patient  were  accustomed  to  the  use  of  whiskey,  as  the  long  time 
necessary  for  narcosis  shows  he  must  have  been,  the  changes  of 


PRIMARY    SYNCOPE    FROM    CHLOROFORM.  323 

the  organs  could  not  be  explained  on  this  theory.     They  then 
go  on  to  a  consideration  of  prophylaxis. 

Primary  Sjiicope  from  Chloroform. 

In  a  recent  work-  received  by  us  from  the  author,  Dr.  Robert 
Kirk,  of  Edinburgh,  states  :  "The  failure  (as  the  writer  thinks) 
of  the  Hyderabad  Commission  to  throw  a  single  ray  of  light 
on  the  primary  syncope  from  chloroform,  which  has  so  often 
proved  fatal  in  the  human  subject,  has  once  more  prevailed 
on  him  to  take  up  his  pen  in  the  hope  that  his  views  before 
published  may  now  have  a  better  chance  of  acceptance,  or 
at  all  events  may  lead  to  investigation  in  a  new  direction." 
The  new  theory  of  the  author  is  that  there  are  two  forces  act- 
ing— the  chloroform  dissolved  in  the  blood,  and  a  further 
effect  due  to  the  vapor  in  the  pulmonary  cells.  Now  the  action 
of  the  force  must  be  the  ordinarj^  anassthetic  effect  of  the  agent, 
causing  retardation  and  stagnation  of  the  corpuscles  in  the  ves- 
sels, and  a  diminution  of  all  the  processes  going  on  there,  at- 
tended, through  reflex  action,  with  corresponding  results  on 
the  systemic  circulation, 

"If  we  suppose  that  these  processes  are  diminished  by  a 
fourth,  then  the  effect  may  be  compared  to  that  of  a  tourniquet 
compressing  one  of  the  iliac  arteries ;  if  by  a  half,  to  a  similar 
compression  of  the  abdominal  aorta. 

"  It  must  be  evident  that  if  such  be  the  intensity  of  the  force, 
its  sudden  withdrawal  will  be  attended  with  the  liability  of 
syncope,  as  would  be  the  sudden  removal  of  the  tourniquet  in 
the  two  supposed  cases.  Now,  when  the  patient  is  allowed  to 
breathe  fresh  air,  the  force  ceases  to  act  with  remarkable  sud- 
denness, for  after  a  few  inspirations  it  is  gone.  The  result  is  a 
violent  reaction — a  violent  rebound  or  whirl  of  the  circulation 
terminating,  in  its  most  pronounced  form,  in  syncope. 

This,  and  nothing  else  than  this,  I  believe  to  be  the  cause  of 
primary  chloroform  syncope. ' ' 

"■'^AM'ew  Theory  of  Chloroform  Syncope,  pp.  55.  Edinburgh  and 
Glasgow.     John  Menzies,  1890. 


324  ARTIFICIAL    ANAESTHESIA. 

Our  author's  rules  are  to  keep  up  a  continuous  atmosphere 
of  vapor  until  deep  anaesthesia  is  induced,  and  not  to  stop  short 
of  this  point  for  an^^  reason  whatever,  no  matter  what  the 
operation.     See  p.  44. 

There  is  one  point  he  would  stop  at ;  it  is  when  the  face 
assumes  a  gray-greenish  look,  which  to  him  is  always  the  danger 
signal  or  fatal  symptom.  A  very  good  hint  is  to  have  the 
apartment  heated  to  65°  or  70°  F. ,  and  to  have  two  towels  or 
flannel  bags  thoroughly  warmed  and  dried  by  the  fire. 

"If  the  above  theory  of  the  nature  of  chloroform  syncope  be 
correct,  it  follows  that  we  could  illustrate  it  at  will  on  almost 
every  human  being  (except  perhaps  in  parturient  females  and 
a  few  others)  as  we  can  do  on  the  cat.  All  that  is  necessary  is 
to  make  any  one  breathe  2^  per  cent,  of  the  vapor  for  a  minute 
or  so  and  suddenly  stop  short,  when  the  syncope  will  be  almost 
certain  to  show  itself  at  the  end  of  the  next  minute.  (See 
p.  25.)^ 

"This,  he  states,  is  exactly  what  happened  in  the  fatal  case 
(No.  1)  of  chloroform  syncope,  in  a  girl  at  Winlaton,  near  New- 
castle,"^ England,  who  breathed  the  vapor  for  a  minute  and 
died  at  the  end  of  the  next  minute.  The  other  two  cases  :  (2) 
Patrick  C;  age  not  stated;  March,  1848.  Disease,  fistula; 
had  taken  chloroform  once  previously;  time  of  inhalation  about 
one  minute  ;  quantity  consumed,  half  a  drachm  ;  lapse  of  time 
till  death,  one  minute ;  patient  on  his  side.  Chloroform  was 
administered  on  a  handkerchief  or  towel.  Immediately  the 
operation  commenced,  the  patient  became  pulseless,  his  pulse 
previously  being  full  and  natural. 

"  3.  I.y. ;  aged  seventeen  ;  Hotel  Den,  Lj'ons,  January,  1849. 
Amputation  of  finger.  Chloroform  was  dropped  upon  gauze 
spread  over  the  face,  leaving  a  free  passage  of  air.  At  the  end 
of  five  minutes  the  patient  still  felt  and  spoke ;  at  the  end  of 
six  minutes  he  became  restless  and  still  spoke.  One  drachm 
and  a  half  of  chloroform  had  now  been  given  ;  pulse  regular 
and  good.  He  now  struggled  violently,  and  within  a  quarter 
of  a  minute  the  pulse  at  the  wrist  became  imperceptible.     The 

-'■  Loudon  Lancet,  Feb.  8,  1890,  p.  316. 


PRIMARY    SYNCOPE    FROM    CHLOROFORM.  325 

gauze  was  removed ;  no  pulse  anywhere  to  be  felt  and  no  car- 
diac sounds  audible.  Respiration  continued  and  ceased  in  half 
a  minute.  Means  of  resuscitation  were  emploj^ed,  and  respira- 
tion reappeared  in  two  minutes'  time,  and  then  again  gradually 
ceased.  The  pulse  did  not  return.  Our  author  then  states 
that  if  his  theory  does  not  furnish  the  true  explanation  in  such 
cases,  there  is  no  other  possible  theory  which  can  justify  us  in 
maintaining  that  chloroform  is  a  safe  agent  in  all  cases,  and  the 
doctrine  of  Simpson  and  Syme  must  be  erroneous." 

The  most  conclusive  statements  and  experiments  are  given  in 
the  paper  of  Dr.  MacWilliam,  in  answer  to  the  strictures  and 
conclusions  published  by  Dr.  Lawrie.* 

"In  the  Med.  Chron.,  January  1891,  Surgeon-Major  Lawrie, 
in  an  article  on  the  Hyderabad  Chloroform  Commission,  makes 
some  comments  on  certain  results  obtained  by  me  in  a  recent  in- 
vestigation on  the  action  of  chloroform  and  ether,  published  in 
the  Bi^t  M.  J.,  October  11,  18  and  25,  1890. 

"In  my  paper  I  described  the  frequent  occurrence  of  dilata- 
tion of  the  whole  heart  under  the  influence  of  anaesthetic  doses 
of  chloroform.  Such  dilatation  was  not  due  to  changes  in  the 
pulmonary  circuit  or  to  fall  of  arterial  pressure." 

Dr.  Jiawrie  urges  that  the  cardiac  dilatation  was  due  to  ob- 
struction of  the  circulation  of  the  lungs,  or  to  this  along  with 
a  fall  in  the  blood  pressure.  He  says  :  ' '  The  irregularities  in 
the  tracings  of  the  Glasgow  Committee,  and  Prof.  MacWilliam 's 
more  recent  '  bogie '  of  dilatation  of  the  heart,  are  due  to  ob- 
struction of  the  circulation  in  the  lungs  through  interference 
with  or  irregularity  of  the  respiration. ' '  And  later  :  ' '  Obstructed 
circulation  in  the  lungs  and  a  rapidly  falling  blood  pressure  are 
more  than  enough  to  account  for  the  dilatation  of  the  whole 
heart,  which  occurred  in  his  experiments,  and  which  he  wrongly 
attributed  to  the  direct  action  of  chloroform." 

' '  Now  this  hypothesis  of  Surgeon-Major  Lawrie  can  be  briefly 
and  conclusively  disposed  of.  There  is  an  abundance  of  decisive 
evidence  available.  First,  as  regards  the  alleged  influence  of 
obstruction  of  the  circulation  in  the  lungs  in  causing  dilatation 

*  Medical  Chronicle,  Manchester,  1891,  xiii.,  352-355. 


326  ARTIFICIAL    ANESTHESIA. 

of  the  heart.  In  my  paper  in  the  Bnt  M.  J.,1  stated  the  fact 
that  such  an  explanation  was  incompetent  to  explain  the  cardiac 
condition,  since  the  ivhole  organ  was  dilated  in  mj'^  experiments. 
Dilatation  of  the  right  side  of  the  heart  might  conceivably  (if 
there  were  no  evidence  to  the  contrary)  be  accounted  for  by  the 
presence  of  pulmonar}"  obstruction.  But  dilatation  of  the  left 
side  [e.g.,  the  left  auricle)  could  clearlj^  not  be  accounted  for  in 
the  same  way,  since  pulmonary  obstruction  necessarily  dimin- 
ishes in  large  measure  the  flow  of  blood  into  the  left  auricle, 
and  this  part  becomes  small  and  collapsed.  This  seemed  so  ob- 
vious to  me  that  I  did  not  discuss  the  matter  at  any  great 
length. 

"I  shall  now  state  briefly  some  facts  in  regard  to  Surgeon- 
Major  Lawrie's  hypothesis  of  obstructed  circulation  in  the 
lungs : 

"(1)  There  is  no  proof  whatever  of  the  occurrence  of  pul- 
monary obstruction  from  the  administration  in  mammals  of 
anaesthetic  doses  of  chloroform  sufficiently  diluted  with  air,  as 
was  the  case  in  my  experiments,  the  amount  of  chloroform 
vapor  in  the  air  never  exceeding  four  per  cent. 

"(2)  On  the  other  hand,  there  is  decisive  proof  that  pul- 
monary obstruction  was  not  present  in  my  experiments.  Ob- 
struction of  the  circulation  would  necessarily  cause  distension 
of  the  pulmonary  artery  as  well  as,  and  indeed  earlier  than,  dis- 
tension of  the  right  heart.  The  pulmonary  artery  would  be- 
come large  and  tense  in  consequence  of  the  increased  peripheral 
resistance  to  the  outflow  of  blood  from  that  vessel.  Then  the 
increased  tension  would  react  upon  the  right  heart  and  cause 
distension  there  also.  But  in  my  experiments  there  was  no  dis- 
tension of  the  jpulmonary  artery  during  the  administration  of 
chloroform.  The  vessel  did  not  become  distended  ;  it  was  soft 
and  compressible,  and  the  tension  within  it  was  low.  It  is  quite 
certain,  then,  that  pulmonary  obstruction  could  not  have  been 
the  cause  of  the  dilatation  even  of  the  right  side  of  the 
heart. 

"(3)  Even  if  pulmonary  obstruction  had  been  present — as 
was  not  the  case — such  obstruction  could  not  have  produced  the 
condition  which  I  described,  or  anything  at  all  similar  to  it. 


PRIMARY    SYNCOPE    FROM    CHLOROFORM.  327 

"  I  liave,  on  various  occasions,  purposely  brought  about  a 
condition  of  pulmonary  obstruction  by  niecbanical  means  with  a 
view  to  studying  the  features  of  this  condition.  This  I  did  by 
injecting  into  one  of  the  great  systemic  veins  some  particulate 
substance,  e.g..^  Ij'copodium  powder,  which  would  cause  embo- 
lism of  the  pulmonary'  vessels,  and  so  obstruct  the  circulation 
in  the  lungs.  When  such  a  substance  is  injected  into  the  vein, 
it  rapidly  passes  through  the  right  heart  into  the  pulmonary 
vessels,  speedily  causing  more  or  less  extensive  and  sudden  ob- 
struction of  the  pulmonary  circulation,  according  to  the  amount 
and  suddenness  of  the  injection. 

"The  effects  resulting  from  the  plugging  of  the  minute  pul- 
monary vessels  induced  in  this  way  are  very  noteworthy,  and 
illustrate  clearly  the  consequences  of  obstruction  of  the  circula- 
tion in  the  lungs.  The  pulmonary  artery  swells  up  and  becomes 
largely  distended,  while  at  the  same  time  the  vessel  feels  hard 
and  tense  to  the  touch  ;  the  pressure  within  the  vessel  is  greatly 
elevated.  The  right  ventricle  and  the  right  auricle  then  par- 
take in  the  condition  of  distension,  being  unable  to  discharge 
their  contents  in  the  normal  fashion  in  face  of  the  greatly 
augmented  resistance  in  front.  The  lungs  become  pale  and 
anaemic. 

"Meanwhile,  it  is  important  to  observe  that  the  left  auricle 
becomes  small  and  collapsed-looking  in  consequence  of  the  ob- 
stacle offered  to  the  passage  of  the  blood  through  the  lungs. 
Strong  respiratory  efforts,  with  convulsions  of  the  asphyxial 
type  (accompanied  by  spasmodic  contraction  of  the  systemic 
arteries),  supervene  in  consequence  of  the  stoppage  of  the  res- 
piratory purification  of  the  blood;  the  medullary  centres  become 
violently  stimulated  by  the  venous  character  of  the  blood. 
Death  speedily  follows. 

"  It  is  unnecessary  to  enter  closely  into  a  comparison,  or  rather 
contrast,  of  the  typical  illustration  of  pulmonary  obstruction 
here  afforded,  and  the  condition  of  cardiac  dilatation  which  I 
have  described  as  occurring  under  the  influence  of  chloroform. 
It  is  obvious  that  obstruction  of  the  circulation  in  the  lungs 
produces  changes  strikingly  different  from  those  that  result  from 
the  action  of  chloroform  ;  and  that  the  hj-pothesis  of  pulmonary 


328  ARTIFICIAL    ANAESTHESIA. 

obstruction  may  at  once  be  dismissed  as  entirely  insufficient  and 
inapplicable,  as  far  as  an  explanation  of  the  cardiac  dilatation 
occurring  under  chloroform  is  concerned. 

' '  Seeing  that  it  is  easy  to  dispose  of  the  question  of  pulmonary 
obstruction  in  regard  to  the  effects  of  chloroform  upon  the 
heart,  I  shall  now  advert  briefly  to  the  possibility  of  cardiac  di- 
latation being  dependent  on  a  rapidly  falling  blood-pressure,  as 
alleged  by  Dr.  Lawrie. 

"  This  is  a  matter  which  I  carefully  considered  in  my  paper, 
and  in  regard  to  which  I  was  able  to  state  definitely  that  the 
cardiac  dilatation  is  not  due  to  a  fall  of  blood-pressure.  This  is 
conclusively  proved  by  the  following  facts:  (1)  Dilatation  of  the 
heart  does  not  by  any  means  always  run  parallel  to  the  fall  of 
pressure  which  ordinarily  results  from  the  administration  of 
chloroform.  Sometimes  there  is  a  very  marked  fall  of  pressure, 
with  little  or  no  dilatation  of  the  heart ;  while  at  other  times 
the  heart  begins  to  dilate  before  the  pressure  begins  to  fall.  (2) 
Moreover,  the  heart  in  some  instances  begins  to  dilate  during 
the  temporary  rise  of  pressure  which  at  times  precedes  the  fall. 
(3)  Further,  there  may  be  distinct  dilatation  of  the  heart  with- 
out any  change  of  pressure  at  all.  (4)  Lastly,  it  can  easily  be 
shown  that  a  simple  fall  of  pressure,  equal  in  amount  to  that 
which  ordinarily  occurs  under  chloroform,  induced  by  means 
which  do  not  directly  affect  the  heart  {e.g.^  section  of  a  vaso- 
motor nerve,  hasmorrhage,  etc.),  does  not  cause  dilatation  of  the 
organ,  as  chloroform  does. 

"It  is  clear,  then,  that  the  dilatation  of  the  heart  brought 
about  by  chloroform  cannot  be  due  to  obstruction  of  the  circu- 
lation in  the  lungs,  or  to  a  fall  of  systemic  blood-pressure  ;  it 
must  result- from  a  depressing  influence  exerted  by  the  anaes- 
thetic on  the  organ  (1)  directly,  or  (2)  through  the  vagus 
nerves. 

"Finally,  as  this  depressing  influence,  leading  to  dilatation, 
is  readily  manifested  after  section  of  both  vagi,  it  is  obvious 
that  chloroform  must  act  upon  the  heart  directly, 

' '  I  cannot  help  feeling  that  even  a  comparatively  slight  amount 
of  actual  observation  of  the  features  and  results  of  a  simple 
lowering  of  the  blood-pressure  and  of  real  pulmonary  obstruc- 


CHLOROFORM  IN  DENTAL  SURGERY.      329 

tion  would  have  prevented  Surgeon -Major  Lawrie  from  putting 
forward  and  adhering  to  such  a  hypothesis  as  I  have  here  dis- 
cussed— a  hj'pothesis  at  once  insufficient,  absolutely  untenable, 
and  in  conflict  with  large  and  somewhat  elementary  facts  in  the 
physiology  of  the  circulation."- 


CHAPTER    X. 

Chloroform  in  Dental  Surgery. 

A  valuable  communication  has  been  received  from  Frederic 
Hewitt,  M.D.  (anaesthetist  to  three  of  the  London  hospitals), 
giving  his  views  of  chloroform  as  an  anaesthetic,  and  more 
especially  in  dental  surgery.  It  is  almost  the  united  opinion 
both  of  the  medical  and  dental  profession,  in  this  connection, 
that  chloroform  is  too  dangerous  an  agent  to  employ,  especially 
in  the  extraction  of  teeth.  Dr.  Hewitt's  knowledge  and  long 
experience  should  give  his  opinion  on  this  subject  great  influ- 
ence with  the  dental  profession.  The  paper  was  read  in  the 
city  of  Edinburgh,  where  chloroform  is  held  in  such  high  favor, 
and  before  the  British  Dental  Association  as  late  as  August, 
1895. 

I.  Introducing  the  subject,  he  states :  "  Under  what  circum- 
stances should  chloroform  be  employed  as  an  angesthetic  in 
dental  surgery?  For  many  years  past  every  member  of  the 
medical  and  dental  professions,  indeed  I  may  say  every  thought- 
ful individual  throughout  the  civilized  world,  has  been  await- 
ing some  authoritative  statement  on  this  subject.  Although 
the  conservative  dentistry  of  recent  years  has  dealt  a  salutary 
blow  at  the  reckless  removal  of  decayed  teeth,  the  operation  of 
tooth  extraction  is  undoubtedly  necessary  in  some  millions  of 
cases  annually,   and  with  this  necessity  for  tooth  extraction 

••''  In  reply  to  Lawrie  on  the  Hyderabad  Chloroform  Commission. 
Same  journal,  1891,  xiii.,  276-279,  ch.  i. 

22 


330  ARTIFICIAL    ANAESTHESIA. 

there  is  naturallj^  enough  demand  for  the  painless  performance 
of  these  operations.  It  therefore  seems  to  me  that  it  is  clearly 
the  duty  of  the  dental  profession  to  possess  some  established  ^ 
and  recognized  principles  for  the  guidance  of  its  members  in 
this  important  part  of  their  practice.  Any  one  who  administers 
a  general  anaesthetic  for  a  surgical  operation  takes  upon  him- 
self a  responsibility  that  is  too  often  lightly  estimated.  The 
life  of  the  patient,  for  the  time  being,  is  completely  delivered 
into  his  hands.  Prolonged  practice  with  the  most  lethal  anaes- 
thetics may  give  the  administrator  of  them  a  kind  of  contempt 
for  their  dangers,  but  the  dangers,  although  doubtless  lessened 
by  the  capabilities  of  such  anesthetics,  are  nevertheless  pres- 
ent. Now,  wdth  regard  to  the  selection  of  appropriate  anaes- 
thetics for  the  comparatively  trifling  operation  of  tooth  extrac- 
tion, there  should  be  absolute  unanimity. 

"There  are  several  reasons  for  the  present  occasion  being  a 
particularly  auspicious  one  for  the  discussion  of  this  subject. 
In  the  first  place  there  can  be  no  doubt  that  within  the  past 
few  years  we  have  become  possessed  of  many  fresh  physiologi- 
cal data  concerning  the  action  of  chloroform.  In  the  next 
place,  the  columns  of  periodicals  specially  devoted  to  advance- 
ment in  dental  science  have  for  some  time  past  been  frequently 
occupied  by  notices  of  deaths  under  chloroform  and  by  warning 
editorial  articles. ' ' 

II.    Tlie  Lines  Upon  Whicli  tlie  Inqniry  Has  Been 

Conducted. 

"Let  me  now  briefly  explain  the  hues  upon  which  the  pres- 
ent inquiry  is  based.  I  have  taken  a  period  of  fifteen  years, 
i.e.,  from  1880-1894  inclusive,  and  I  have  exerted  every  means 
in  my  power  to  obtain  particulars  of  all  fatalities  which  have 
occurred  during  this  period  in  Grreat  Britain,  in  connection  with 
the  use  of  anaesthetics  for  dental  operations.  It  seemed  advis- 
able to  take  a  definite  period  of  time,  and  I  fixed  this  at  fifteen 
years,  partly  because  I  have  myself  collected  records  of  deaths 
under  anaesthetics  for  this  period  ;  partly  because  within  the 
past  ten  or  fifteen  years  the  records  of  deaths  under  anaesthetics 
have  become  fuller  and  more  reliable  than  they  formerly  were. 


CLASSIFICATION    AND    ANALYSIS    OF    CASES.       331 

and  partly  because  by  analyzing  recent  cases  one  is  more  likely 
to  obtain  additional  information  to  that  already  published,  than 
when  dealing  with  long-forgotten  casualties. 

"I  very  much  regret  to  say,  however,  that  although  by  the 
system  of  inquiry  which  lias  been  followed,  several  cases  have 
been  brought  to  light  which  were  hitherto  unavailable  for  con- 
sideration, and  numerous  facts  in  connection  with  already 
recorded  cases  have  been  elicited,  there  is  much  ground  for  the 
belief  that  the  inquiry  by  no  means  includes  every  fatality  which 
has  occurred  in  Great  Britain  during  the  past  fifteen  years. 
Even  in  England,  where  coroners'  inquests  are  invariably  held 
when  a  patient  dies  under  an  angesthetic  administered  for  a 
dental  operation,  the  facts  of  the  case  may  never  pass  beyond 
the  coroner's  court,  or  the  columns  of  some  obscure  local 
paper.  But  in  Scotland,  where  coroners'  inquests  are  unknown, 
a  comparatively  large  number  of  cases  must  necessarily  elude 
the  vigilance  of  an  inquiry  such  as  the  present.  When  I  had 
satisfied  myself  that  I  had  obtained  as  many  records  as  time 
and  other  circumstances  would  permit,  I  proceeded  to  classify 
and  analyze  the  cases  in  the  manner  I  shall  now  describe.'' 

HI.— Classification  and  Analj  sis  of  Causes. 

"The  following  table  (Table  I.)  shows  the  total  number  of 
cases  of  which  records  could  be  obtained. 

"  There  are  certain  interesting  points  in  connection  with  this 
table  to  which  I  shall  now  refer.  In  the  first  place,  we  cannot  but 
be  struck  by  the  fact  that  in  Great  Britain  no  less,  and  in  all  prob- 
ability considerably  more,  than  37  persons  have  died  in  connection 
with  the  use  of  general  anaesthetics  for  dental  operations  during 
the  past  fifteen  years.  In  the  second  place,  we  find  that  out  of 
this  total  of  37  fatal  cases  no  less  than  27  occurred  in  connec- 
tion with  the  use  of  chloroform  ;  and  that  if  we  include  the 
chloroform-and-morphine  case,  the  chloroform-and-ether  case, 
and  the  2  cases  which  arose  in  connection  with  the  use  of  the 
so-called  '  methylene '  (which  experience  has  shown  to  consist 
largely  of  chloroform),  we  may  say  that  of  the  37  cases  no  less 
than  31  took  place  in  association  with  the  use  either  of  chloro- 
form or  some  combination  containing  chloroform.    In  the  third 


332 


ARTIFICIAL    ANESTHESIA. 


place,  we  note  there  is  only  one  recorded  etlier  fatality.  I 
have  made  careful  inquiries  as  to  this  one  case,  and,  without 
entering  into  detail  here,  I  may  say  that  it  should  properly  be 
excluded  from  the  table,  for  not  only  was  the  patient  in  such  a 
condition  of  health  that  the  administration  of  any  anaesthetic 
at  the  time  was  extremely  hazardous,  but  death  arose  from 


Table  I. — Deaths  in  Connection  with  General  Ancesthetics 
Administered  for  Dental  Operations  in  Great  Bi'itain 
(1880-1894,  inclusive)  =  Z1. 


Anaesthetic  Used. 


Series  1.  Chloroform 

"  2,  Chloroform,  followed  by  sub 
cutaneous  injection  of 
morphine 

"  3.  Chloroform  3  parts,  ether  1 
part,  in  mixture 

"    4.    "Methylene" 

"     5.  Ether 

"    6,  Nitrous  oxide  gas 


Scotland. 


O  fl  "^ 


12 


14 


England 

AND  Wales 

(excluding 

London). 


S  rt  <i>  SS 


15 


21 


London. 


P-l  bO 


m 


CD  g  ^Ch  § 
o  c-  O)  2  S- 

all- 


mechanical  asphyxia,  principally  due  to  a  cancerous  growth  of 
the  mouth,  and  possibly  also  to  the  entrance  of  blood  into  the 
larynx.  In  the  fourth  place,  I  would  remark,  in  connection 
with  the  nitrous  oxide  fatalities,  that  one  of  them  occurred 
from  the  entrance  of  an  extracted  tooth  into  the  larynx.  But, 
as  in  the  ether  case,  I  have  added  this,  so  that  it  may  be  said 
that  every  possible  case  has  been  included. 

"We  next  pass  to  a  fuller  consideration  of  the  chloroform 


GENERAL    CONDITION.  333 

fatalities  themselves.  These,  27  in  number,  I  have  arranged 
in  two  groups,  viz.  : 

"  Group  1. — Cases  reported  with  sufl&cient  fulness  to  admit  of 
■comparisons  and  analj-ses  being  made  of  them  ;  and 

"  Group  2. — Cases  with  sufficient  data  to  admit  of  any  such 
classification  or  analysis. ' ' 

(We  have  had  to  omit  the  table  for  want  of  space.) 

"  I  may  say,  however,  that  no  case  has  been  included  in  this 
group  unless  it  is  to  be  found  reported  in  one  of  the  leading 
medical  or  dental  journals,  or  unless  I  have  been  able  to  thor- 
oughly satisfy  myself,  through  the  medium  of  correspondents, 
that  it  actually  took  place.  Should  any  doubt  exist  in  any  one's 
mind  as  to  these  cases  I  shall  be  much  pleased  to  place  my  ref- 
erences at  his  disposal. ' ' 

Sex. 

"Of  the  19  cases  5  were  males  and  14  females.  This  pre- 
ponderance of  female  over  male  patients  is  to  be  explained  by 
the  fact,  with  which  all  dental  practitioners  must  be  familiar, 
that  the  great  majority  of  those  who  require  anaesthetics  for 

dental  operations  are  women "Women  and  children  are 

the  best  subjects  for  chloroform,  and  I  have  no  hesitation  in 
saying  that  if  men  of  vigorous  build  constituted  the  majority 
of  patients  requiring  angesthetics  for  dental  operations,  the 
number  of  accidents  under  chloroform  would  be  even  greater 
than  at  present. ' ' 

Age. 

"  Most  of  the  patients  were  young,  the  highest  recorded  age 
being  37,  the  lowest  8  to  10  years.  This  is  again  to  be  explained 
by  the  reasons  which  I  have  just  given." 

General  Condition. 

"Taken  collectively,  there  was  no  case  with  any  condition 
which  precluded  the  use  of  an  anaesthetic  or  which  rendered 
anaesthesia  perilous.  Experience  has  now  convinced  most 
thoughtful  observers  that  the  presence  of  a  'weak  heart,'  or, 
in  fact,  the  existence  of  cardiac  disease,  in  no  way  contra-indi- 
cates  the  employment  of  an  appropriate  anaesthetic." 


334  ARTIFICIAL    ANESTHESIA. 

Preparation. 

'*  Nothing  is  said  as  to  the  regulation  of  the  diet  or  looseness 
of  the  attire  in  nine  of  the  nineteen  cases.  Of  the  remaining 
ten  there  is  evidence  of  the  diet  having  been  regulated  in  six 
cases,  and  of  the  attire  having  been  loosened  before  the  admin- 
istration in  five.  In  onlj?^  two  cases  is  there  a  note  of  both  of 
these  precautions  having  been  adopted.  In  one  case  there  is 
evidence  that  no  precautions  were  taken  at  all ;  in  fact,  the  pa- 
tient was  attired  in  a  tight-fitting  new  dress." 

Posture. 

"  .  .  .  .  Thus  we  find  that  in  one  case  the  patient  was  in  the 
sitting  posture  ;  in  three  cases  in  the  sitting  or  semi-recumbent 
posture  ;  in  three  cases  in  the  semi-recumbent  posture  ;  in  one 
in  the  semi-recumbent  or  dorsal  posture  ;  and  in  four  cases  in 
the  dorsal  posture.  In  other  words,  there  is  evidence  that  the 
patient  was  either  sitting  or  semi-recumbent  in  seven  of  the 
twelve  cases  in  which  any  details  as  to  posture  are  given. 

"The  posture  of  a  patient  during  the  administration  of  chlo- 
roform for  a  dental  operation  is  a  matter  to  which  attention 
should  be  carefully  directed.  Most  medical  and  dental  practi- 
tioners are  aware  of  the  influence  which  a  more  or  less  vertical 
position  of  the  body  may  exert  upon  the  circulation — effects 
which  are  directly  dependent  upon  the  force  of  gravity.  But 
there  would  appear  to  be  comparatively  few  who  fully  realize 
the  fact  that  in  dental  operations  generally,  and  more  particu- 
larly in  dental  operations  under  chloroform,  the  circumstances 
which  usually  attend  the  administration  of  the  anaesthetic  are 
very  favorable  to  the  occurrence  of  arrested  breathing.  It  will 
be  well  to  say  something  as  to  the  effects  of  posture  upon  the 
circulation. 

"  A  very  complete  research  by  Dr.  Leonard  Hill,  communi- 
cated not  long  ago  to  the  Royal  Society,  is  of  importance  in 
this  connection.  Dr.  Hill  finds  the  circulation  in  the  lower 
animals  to  be  directly  influenced  by  the  force  of  gravity,  the 
arterial  tension  in  the  carotid  arteries  rising  in  the  feet-up  and 
falling  in  the  feet-down  posture.  He  further  finds  that  the 
splanchnic  vaso-motor  mechanism,  which  regulates  the  quantity 


POSTURE.  335 

of  blood  in  the  splanchnic  area,  compensates  for  these  changes 
in  the  tension  of  the  carotids,  and  that,  when  the  mechanism  is 
intact,  and  the  heart  is  acting  efficiently,  raising  the  trunk  and 
lowering  the  feet  has  no  dangerous  effect  upon  the  circulation, 
for  by  the  constricting  action   of  the  splanchnic  mechanism, 
blood  is  prevented  from  accumulating  in  the  splanchnic  area 
and  the  heart,   and  therefore  the  carotids  and  the  brain  are 
kept  properly  supplied.      But  if  the   splanchnic  vaso-motor 
mechanism  be  damaged,  as,  for  example,  by  the  use  of  large 
quantities  of  chloroform,  by  asphyxia,  or  by  other  causes,  an 
alarming  and  perhaps  fatal  attack  of  syncope  may  attend  eleva- 
tion of  the  trunk,  for  the  splanchnic  area  is  full  of  blood,  and 
the  arterial  system  is  comparatively   empty.     Dr.    Hill  laj^s 
stress,  too,  on  the  fact  that  if  the  heart's  action  has  become  de- 
pressed from  an  overdose  of  chloroform  or  other  causes,  this 
elevation  of  the  trunk  will  be  even  more  liable  to  end  disas- 
trously.    But  should   the   patient's  circulation   be   extremely 
feeble  (from  nervous  apprehension,  functional  or  organic  dis- 
ease,  ansemia,   etc.),  before  the  administration,    or  should  it 
become  greatly  depressed  (from  the  use  of  too  small  or  of  too 
large  quantities  of  the  anaesthetic,  from   vomiting,  from  as- 
phyxial  complications,  or  from  surgical  shock)  during  the  ad- 
ministration, any  elevation  of  the  trunk  from  the  horizontal 
plane  may  certainly  be  fraught  with  considerable  danger. 

"Extension  of  the  Head  and  Neck.— It  is  a  common 
practice  in  dental  surgery  for  the  head  to  be  thrown  well  back- 
wards upon  the  trunk  in  order  to  allow  of  the  extraction  of 
upper  teeth.  This  procedure,  however,  has  the  effect  of  bring- 
ing the  base  of  the  tongue  and  epiglottis  away  from  the  pharynx 
and  larynx  respectively,  so  that  the  act  of  swallowing  is  ren- 
dered difficult  or  impossible.  Any  one  may  satisfy  himself 
with  regard  to  this  point  by  making  the  experiment  upon  his 

own  person. 

"  When  extension  of  the  head  and  neck  is  practiced  during 
deep  anaesthesia,  another  danger  comes  into  operation,  viz., 
that  of  foreign  substances  actually  entering  the  now  insensitive, 
open,  and  unprotected  larynx." 

Flexion  of  the  Head  upon  the  Sternum.     Opening  the 


336  ARTIFICIAL    ANESTHESIA. 

Mouth  Very  Widely  by  Means  of  Props  or  Gags. — By 
placing  one  or  more  pillows  under  the  head,  without  raising  the 
shoulders,  the  tongue  will  tend  to  touch  the  pharyngeal  wall, 
and  the  breathing  may  thus  become  impeded,  stertor  passing 
into  complete  obstruction.  This  was  pointed  out  by  Bowles. 
A  similar  state  of  things  may  arise  during  the  extraction  of 
lower  teeth,  respiration  completely  ceasing  so  long  as  the  lower 
jaw  is  driven  down  towards  the  sternum.  Again,  if  the  mouth 
be  opened  very  widely  by  a  prop  or  a  gag,  respiration  will  be 
liable  to  become  arrested  when  the  patient  is  ansesthetized,  the 
depression  of  the  lower  jaw  having  the  same  effect  in  approxi- 
mating the  tongue  to  the  pharynx  as  when  the  whole  head  is 
flexed  by  means  of  pillows. 

In  the  semi-recumbent  and  dorsal  postures  the  tongue  maj% 
during  properly  established  anaesthesia,  gravitate  towards  the 
pharyngeal  wall  and  obstruct  breathing.  I  have  frequently 
demonstrated  at  the  Dental  Hospital  the  great  difference,  in 
regard  to  the  occurrence  of  obstructive  stertor,  between  a 
nearly  vertical  posture  and  a  position  approaching  the  semi- 
recumbent — the  latter  being  a  very  favorite  one  for  dental  ope- 
rations. I  am  now  speaking  of  nitrous  oxide  cases,  but  the 
remarks  apply  to  chloroform.  When  the  body  and  head  are 
nearly  vertical  the  tongue  rests  on  the  floor  of  the  mouth,  and 
obstructive  stertor  is  not  likely  to  arise.  When  the  body  and 
head  are  thrown  more  backwards,  as  they  almost  invariably  are 
when  chloroform  is  about  to  be  given,  tongue-stertor  is  far 
more  likely  to  arise,  and  respiration  to  become  embarrassed 
from  this  cause. 

Metliocl  of  Adininistration  and  Quantity  of 
Cliloroforin  Used. 

In  5  of  the  19  cases  no  particulars  are  obtainable  concerning 
the  method  adopted  or  the  quantity  of  chloroform  used.  The 
method  is  referred  to  in  13  cases.  In  3  of  these  a  Skinner's 
mask  was  employed  ;  in  2  a  folded  napkin  ;  in  2  a  piece  of  lint; 
in  2  a  "  napkin  "  (?  folded  or  not);  in  1  a  towel ;  in  1  an  "open 
inhaler;"  in  1  a  Junker's  apparatus;  and  in  1  it  is  stated  that 
the  chloroform  was  administered  "in  the  usual  way."     The 


PHENOMENA    DURING    ADMINISTRATION.  337 

quantit}^  of  chloroform  used  is  given  in  6  of  the  cases.  The 
smallest  quantitj^  was  half  a  drachm ;  the  largest  was  a  little 
over  2  drachms.  If  we  take  "a  little  over" — an  expression 
used  in  2  of  the  cases — to  mean  20  minims,  and  if  we  reckon 
45  minims  to  have  been  employed  in  the  case  in  which  "40  to 
50  minims"  is  mentioned,  the  average  quantity  of  chloroform 
used  in  these  6  fatal  cases  works  out  at  about  2h  drachms. 
Special  reference  will  subsequently  be  made  to  the  2  remark- 
able cases  in  which  only  30  minims  and  40  to  50  minims  respec- 
tively were  employed. 

Natiu'e  of  Operation. 

The  proposed  operation  is  not  stated  in  5  of  the  19  cases ;  in 
1  it  is  said  that  a  "large  number  of  roots  "  had  to  be  removed  ; 
in  4  cases  ' '  several  teeth  ' '  are  referred  to  ;  in  1  case  eighteen 
roots  had  to  be  extracted  ;  in  2  cases  nine  teeth  ;  in  2  cases  six 
teeth ;  in  1  case  the  roots  of  one  tooth  and  then  two  entire 
teeth  ;  in  1  case  three  teeth  ;  in  1  case  one  tooth  and  one  stump ; 
and  in  1  case  one  tooth  only. 

Relation  of  Dangerous  Symptoms  to  Operation. 

In  3  cases  the  dangerous  symptoms  arose  before  the  opera- 
tion ;  in  8  during ;  in  2  during  or  after  ;  in  5  after  ;  and  in  1  it 
is  impossible  to  say  at  what  juncture  they  occurred. 

Phenomena  During  Administration  and  Operation. 
Fatal  Phenomena. 

"The  occurrence  of  dauirerous  sj'mptoms  during  the  admin- 
istration of  an  anaesthetic  for  the  comparatively  minor  opera- 
tion of  tooth  extraction  is  usually  so  disturbing  that  a  cleai'  and 
systematic  statement  is  next  to  impossible. 

"For  example,  breathing  may  so  noiselessly  and  insidiously 
cease  that  the  cessation  may  readily  escape  detection,  the  more 
so  as  thoracic  and  abdominal  movements  may  continue  even 
when  there  is  complete  obstruction  to  the  entry  and  exit  of  air 
to  and  from  the  chest. 

"Amongst  the  19  fatal  cases  there  are  no  less  than  6  (viz., 
Nos.  2,  9,  10,  15,  16  and  18)  in  which  chloroform  was  readmin- 


338  ARTIFICIAL    ANESTHESIA. 

istered  during  the  operation — a  fact  which  corroborates  the 
opinion  that  this  rcadministration  in  dental  surgery  is  hazard- 
ous unless  skilfully  conducted. 

"Chloroform  is  administered  in  very  small  quantities  at  a 
time,  as  I  have  often  seen  it  administered,  and  a  highly  unsat- 
isfactory state  of  affairs  results.  I  believe  Syme's  dictum  was 
that  'drachms  may  save  whilst  drops  may  kill,'  and  there  is  a 
good  deal  of  truth  in  this  remark.  When  chloroform  is  given 
in  too  small  quantities  at  a  time,  and  delay  arises  in  producing 
surgical  anaesthesia,  the  circulation  will  often  show  signs  of 
running  down.  Pallor,  feeble  pulse,  shallow  and  almost  imper- 
ceptible breathing  will  arise.  An  experienced  administrator, 
taking  in  hand  such  a  case  at  such  a  time,  would  add  half  a 
drachm,  a  drachm  or  even  more  of  the  ansesthetic  to  the  lint, 
and  apply  the  latter  more  closely  to  the  face,  with  the  result 
that  respiration  would  quickly  increase  in  force." 

Post-Morteiii. 

"Nothing  is  said  as  to  any  iwst-mortem  having  been  per- 
formed in  8  of  the  cases.  In  4  it  is  stated  that  no  autopsy  was 
made.  In  the  remaining  7  cases  the  particulars  obtainable  are 
so  imperfect  and  meagre  that  no  useful  purpose  would  be  served 
in  classifying  them. ' ' 

We  regret  we  cannot  give  the  whole  of  this  pamphlet  (32 
pages),  but  have  endeavored  to  give  a  full  abstract  and  the 
latter  portion. 


CHAPTER  XI. 

Anaesthesia  by  Chloroform  and  Oxygen. 

In  our  third  edition  (p.  474)  it  is  there  stated  and  published, 
in  1887,*  that  Dr.  Kreutzmann,  of  San  Francisco,  emplo3^ed  not 
the  pure  chloroform,  but  Billroth's  mixture  (three  parts  of 
ether  to  one  of  chloroform)  in  conjunction  with  oxj^gen.     The 

"•■•  Pacific  Medical  and  Surgical  Journal,  August,  1887. 


OXYGEN    WAS    AN    ANTIDOTE    TO    CHLOROFORM.       339 

discoverer  of  this  method  was  Dr.  Neudorfer,  of  Vienna,  who 
claims  on  theoretical  grounds  that  its  emploj^ment  is  entirely 
without  danger.  We  also  published  in  the  same  edition  (p. 
210),  1890,  the  following  case,  illustrating  the  fact  that 

Oxyg-eii  Was  an  Antidote  to  Chloroform. 

"A  young  man  attached  to  the  laboratory  of  the  New  York 
Medical  College  became  asphxiated  from  the  inhalation  of  the 
vapor  of  chloroform ;  and  so  far  had  its  effects  been  carried  that 
he  became  pulseless,  and  all  hopes  of  his  resuscitation  aban- 
doned ;  and  as  all  the  usually  recommended  remedies  had  been 
tried  without  success,  nothing  but  the  death  of  the  j^oung  man 
was  looked  for,  when  I  proposed,  as  a  dernier  resort,  the  appli- 
cation of  pure  oxygen  gas,  as  the  only  chance  by  which  resusci- 
tation could  be  brought  about ;  but  at  the  time  the  proposal 
met  with  opposition  from  the  medical  men  present,  who  were 
anxiously  watching  what  seemed  to  be  the  expiring  efforts  of  the 
poor  bo}^,  expecting  each  moment  to  be  his  last.  Having,  how- 
ever, consented,  the  gas  had  not  been  more  than  a  few  seconds 
applied  to  his  nostrils,  when  he  who  was  apparently  beyond  the 
help  of  human  skill,  and  absolutel}''  in  articido  mortis,  arose  and 
placed  himself  upon  a  chair,  proving  most  conclusively  how 
correct  I  was  in  proposing  the  application  of  oxj^gen  gas  as  a 
remedy  against  the  deleterious  effects  of  chloroform  as  an  anaes- 
thetic." — Dr.  Simeon  AhroJurms. 

I  also  published  the  following  facts  in  corroboration  of  the 
great  value  of  oxygen  gas : 

' '  Dr.  Loyssel  has  experimented  with  pure  oxygen  and  from 
it  has  obtained  very  good  results.     He  concludes  : 

' '  1st.  That  in  certain  poisonings,  such  as  those  by  chloroforms^ 
ether,  opium,  sulphuretted  hydrogen,  carbon  dioxide,  cyanhy- 
dric  acid,  oxygen  constitutes  the  only  means  of  recalling  the 
patient  to  life,  when  all  else  has  failed. 

"  2d.  That  its  presence  in  the  operating  room  is  certain  pro- 
tection against  fatal  accidents  from  the  use  of  anaesthetics. 

"3d.  That  it  succeeds  equally  well  in  asphyxia  caused  by 
strangulation,  by  immersion,  by  toxic  gases,  etc.,  as  well  as  with 
the  new-born,  in  condition  of  apparent  death. 


340  ARTIFICIAL    ANESTHESIA. 

"4th.  Life  can  almost,  with  certainty,  be  maintained  in  all 
cases  where  respiration  has  not  entirely  ceased,  even  if  there 
are  long  intervals  between  the  inspiratory  efforts. 

"  5th,  If  the  respiratory  and  circulatory  functions  have  been 
completely  arrested  for  a  short  time,  they  may  be  re-established 
by  means  of  oxygen,  which  it  is  necessary  to  administer  with 
perseverance,  even  when  it  is  believed  that  all  efforts  will  be 
useless.  There  are  reported  many  cases  of  drowned  persons, 
and  of  children  apparently  dead,  who  have  been  saved,  thanks 
to  persistence  in  administering  oxygen. 

"6th.  Oxygen  may  be  inhaled  in  notable  quantity  without 
the  least  danger." 

On  page  202  were  given  a  number  of  careful  experiments  to 
determine  if  it  were  an  anaesthetic,  and  concluded  that  pure 
oxygen  was  not  a  true  anaesthetic,  but  could  be  inhaled  with 
safety  even  in  large  quantities. 

In  February,  1895,  was  published  a  valuable  communication  by 
Dr.  H.  L.  Northrop,  giving  his  reasons  for  the  administration 
of  oxygen  with  chloroform  when  the  latter  is  used  as  an  anaes- 
thetic, and  he  premised  by  stating  that  he  had  administered  it 
in  one  hundred  operations,  from  the  most  minor  to  laparotomy, 
for  haematoma,  amputation  of  breast,  celiotomy  for  ruptured 
liver,  herniotomy,  amputation  of  leg,  and  several  cases  of  ap- 
pendicitis : 

"  The  idea  of  combining  oxj^gen  with  chloroform  for  anaes- 
thetic purposes  occurred  to  me  a  year  and  a  half  ago,  while 
considering  the  physiological  effects  of  chloroform.  Since  then 
I  have  demonstrated  its  practical  utility. 

"A  search  was  made  for  me  in  the  Patent  Office  at  Wash- 
ington ;  I  have  examined  the  Index  Medicus  for  the  past  five 
years  for  articles  bearing  upon  the  subject,  and  I  wrote  to  Lon- 
don hospitals  and  received  a  reply.*  From  none  of  these 
sources  could  I  learn  of  anything  in  regard  to  this  combination. 
Thus  it  would  appear  that  this  is  the  first  instance  in  which 
oxygenated  chloroform  has  ever  been  used. 

*  This  is  the  old  idea  to  go  abroad  for  what  can  be  found  at 
home. 


OXYGEN    WAS    AN    ANTIDOTE    TO    CHLOROFORM.       341 

"Function  must  go  on  even  during  the  anaesthetic  state, 
though,  of  course,  it  is  depressed  and  limited — in  the  first  place 
by  the  presence  in  the  blood  of  a  virulent  poison,  and  in  the 
second  place  because  both  the  cerebro-spinal  and  sympathetic 
nervous  systems  are  partially  overpowered  and  cannot  continue 
their  work.  I  say  partially  overpowered,  because  it  is  the  cen- 
sory  and  motor  nerves  of  the  cerebro-spinal  system  which,  so 
far  as  we  know,  are  most  deeply  and  prominently  poisoned.  To 
prove  this  statement,  the  nerve-centres  of  the  cerebro-spinal 
system  governing  the  respiratory  and  circulatory  functions  are 
not  involved  in  the  poisoning  unless  a  lethal  dose  be  adminis- 
tered, while  at  the  same  time  we  have  a  more  or  less  complete 
paralysis  (if  you  please)  of  all  the  other  motor  and  sensory 
nerves.  Again,  to  aid  in  maintaining  the  circulation,  we  must 
have  a  continuance  of  vaso-motor  influence,  and  this  must  be, 
and  is,  supplied  by  the  sympathetic  nervous  system, 

"This  satisfactorily  proves  that  certain  functions  are  carried 
on  to  some  extent  even  during  the  anaesthetic  state.  To  just 
what  extent  function  is  carried  on  it  is  impossible  to  say,  and, 
in  fact,  it  is  not  at  all  necessari^-  for  us  to  know.  Function  de- 
pends upon  the  oxidation  of  tissue ;  oxygen  is  the  oxidizing 
agent  of  the  body.  Anything  that  lessens  the  supply  of  oxy- 
gen to  the  animal  body  will  interfere  with  its  functions.  The 
extent  to  which  function  is  interfered  with  depends,  of  course, 
upon  how  much  the  supply  of  oxygen  is  lessened.  It  is  cer- 
tain, therefore,  that  we  must  have  oxygen  in  sufficient  amount 
if  function — and,  therefore,  existence,  life,  vitality — is  to  be 
maintained. 

"  Why  is  chloroform  such  a  deadly  anaesthetic?  Why  have 
thousands  of  dollars  been  expended  and  thousands  of  animals 
been  sacrificed,  and  Hyderabad  and  Glasgow  Commissions  been 
appointed  ?  Why  have  medical  men  argued  and  debated  with 
one  another,  vainly  trying  to  solve  this  momentous  question  ? 
Is  it  not  all  for  the  purpose  of  trying  to  determine  why  chloro- 
form kills,  and  to  find  a  safer  method  for  its  administration  ? 

' '  The  vapor  of  chloroform  is  very  heavy — more  than  four 
times  as  heavy  as  atmospheric  air.  Because  of  its  weight, 
when  administered  by  the  open  method,   atmospheric  air  is 


342  ARTIFICIAL    ANESTHESIA. 

partiallj'^  excluded,  and  therefore  the  amount  of  oxj'^gen  ab- 
sorbed is  diminished.  If  the  air  is  mixed  with  chloroform 
mechanicallj',  as  bj"  the  Junker  inhaler,  we  even  then  have  the 
amount  of  oxygen  absorbed  reduced  one-half,  and,  of  course, 
this  is  replaced  bj'  the  absorption  of  an  equal  weight  of  chlo- 
roform. If  the  chloroform  be  given  in  a  more  concentrated 
vapor,  its  weight  is  sufficient  to  prevent  the  absorption  of  oxy- 
gen altogether,  and  death  follows,  in  great  part,  from  complete 
deprivation  of  oxygen. 

"We  have  seen  that  oxj^gen  is  necessary  for  the  maintenance 
of  function ;  function  is  necessary  if  life  exists  ;  chloroform, 
by  the  weight  of  its  vapor  and  by  the  physical  laws  governing 
the  arrangement  and  absorption  of  gases,  displaces  the  oxj'gen 
and  reduces  the  quantity  absorbed  one-half,  even  if  the  atmos- 
pheric air  be  freely  mixed  with  it. 

"  Chloroform,  by  its  weight,  falls  into  the  deepest  and  ultimate 
air-vesicles ;  hence  it  is  brought  into  close  contact  with  the 
blood,  and  rapid  absorption  is  favored.  This,  of  necessity, 
potently  tends  to  surcharge  the  blood  with  chloroform  and  to 
displace  or  decrease  the  normal  amount  of  oxygen,  and  inter- 
feres with  oxidation,  upon  which  function  depends.  For  this 
reason  our  patient's  life  is  endangered,  and  that  is  why,  also, 
pure  oxygen  should  be  mechanically  mixed  with  the  vapor  of 
chloroform." 

Mr.  President:  Your  Anaesthetic  Commission*  begs  leave  to 
make  its  final  report  upon  the  experiments  with  chloroform 
and  oxj^gen,  presenting  to  you  the  data  of  100  cases,  with  a 
few  observations  and  practical  conclusions  as  the  outcome  of 
our  work. 

We  preface  our  tabulated  list  of  cases  by  stating  that  all  of 
our  patients  underwent  a  careful  preliminarj^  physical  examina- 
tion as  regards  heart,  lungs  and  kidnej^s,  the  result  of  the  same 
being  noted  on  anaesthetic  blanks. 

Squibb' s  chloroform  was  used,  and  the  oxygen  was  contained, 
under  pressure,  in  iron  cylinders,  each  of  which  held  forty  gal- 

*  Formal  report  of  the  Ansesthetic  Commission,  of  which  Dr.  H.  S. 
Northrop  was  chairman. 


OXYGEN    WAS    AN    ANTIDOTE    TO    CHLOROFORM.       343 

Ions.  The  oxj-gen  was  passed  througla  the  chloroform,  the 
vapor  thus  formed  conveyed  to  a  mask  or  inhaler,  which  was 
made  to  fit  closely  around  the  patient's  mouth  and  nose.  The 
inhaler  was  provided  with  a  valve  for  admitting  or  excluding 
atmospheric  air,  and  a  rubber  bag,  into  which  the  patient  ex- 
haled when  the  valve  was  closed.  This  simple  form  of  appa- 
ratus was  found  convenient,  portable  and  easily  managed  and 
controlled. 

Complete  augesthesia  was  produced,  as  a  rule,  in  a  shorter 
time  than  can  be  done  by  ether  or  chloroform.  The  shortest 
time  required  to  bring  about  complete  anaesthesia  with  ox5^gen- 
ated  chloroform  was  one-half  minute,  in  one  case,  and  the  long- 
est time  10  minutes.  (The  latter  case  was  an  alcoholic,  and  one 
of  our  earlier  cases,  when  we  were  not  well  acquainted  with  our 
anaesthetic. )  The  average  time  consumed  in  anesthetizing  each 
case  was  4i5(j  minutes,  which  average  is  probably  lower  than 
any  yet  published  for  ether  or  chloroform  administered  by  the 
open  method,  and  possibly  lower  than  any  for  the  closed  in- 
halers (Clover  and  Junker). 

The  quantity  of  chloroform  used  in  many  of  the  cases  was 
certainl}'  insignificant,  and.  of  course,  the  amount  of  oxj^gen 
consumed  must  have  been  in  direct  proportion  to  the  quantity 
of  chloroform  vaporized.  We  could  not  ascertain  the  quantity 
of  oxj'gen  used  in  each  case  ;  one  cylinder,  however,  lasted  for 
about  six  hours  of  anaesthetizing. 

One  of  the  most  prominent  (and,  we  must  say,  pleasing  and 
satisfactory)  conditions  attending  the  use  of  oxygenated  chloro- 
form was  a  rosy  color  and  healthful  blush  of  the  lips  and  cheeks, 
and  a  bright  red  oxygenated  state  of  the  blood  flowing  from  a 
wound.  These  apparent  expressions  of  good  aeration  were 
noticed  by  many  by-standers,  and  are  worthy  of  note  because  of 
the  contrast  presented  to  the  well-known,  death-like  pallor  at- 
tending the  use  of  chloroform  alone. 

Vomiting  occurred  in  about  30  per  cent,  (or  less)  of  the  cases. 
It  has  usually  been  of  short  duration,  consisting  of  a  watery, 
greenish  fluid  (bile  and  mucus),  and  only  an  ounce  or  two  to 
each  case  so  afi'ected.  Some  of  our  patients  had  slight,  tem- 
porary nausea,  others  merely  retching  without  vomiting,  and,  as 


344  ARTIFICIAL    ANiESTHESIA. 

above  stated,  about  30  per  cent,  vomited.  Frequently  retching 
occurred  while  the  patient  was  on  the  operating  table.  This  was 
immediately  and  successfully  controlled  in  all  cases  by  turning 
on  the  current  of  oxygenated  chloroform. 

In  the  matter  of  vomiting  our  anaesthetic  was  put  to  a  pretty 
good  test.  More  than  a  year  ago  Dr.  I.  G.  Smedley  removed  the 
ovaries  of  a  woman  who  was  anaesthetized  with  ether.  She  vom- 
ited persistently  for  one  week  and  her  general  condition  became 
seriously  imperiled.  Previously  to  this  her  cervix  and  perinaeum 
were  restored  by  the  late  Dr.  Groodell,  of  this  city.  Ether  was 
given  this  time  also,  and  she  vomited  for  9  days  after  the  opera- 
tion. She  was  a  case  on  our  list,  nephroraphy  having  been 
performed  by  Dr.  W.  B.  Van  Lennep.  Our  notes  say:  "Con- 
scious in  10  minutes  after  placed  in  bed  at  3  p.m.  No  vomiting 
until  after  9  P.M.,  when  cracked  ice  was  given.  Vomiting  of  a 
thin,  greenish  fluid  in  mouthful  quantities  at  intervals  all  night." 
The  next  morning  the  patient's  stomach  and  liver  were  quiet^ 
and  remained  so,  an  uneventful  recoveiy  following. 

Oxygenated  chloroform  usually  slows  the  pulse,  and  the  more 
deeply  the  patient  is  anaesthetized  the  more  slowly  the  heart 
beats,  but  the  pulse  is  full  and  strong.  The  respirations  are 
apparently  not  affected.  The  respiratory  movements  are  cer- 
tainly not  labored  or  excited,  though  in  one  or  two  cases  the 
respirations  were  irregular,  at  one  time  fast,  at  another  slow. 

Recovery  takes  place  very  quickly,  our  patients  often  being 
wide  awake  in  10  or  15  minutes  after  they  are  placed  in  bed, 
and  almost  invariably  without  any  delirium  or  sign  of  intoxica- 
tion. As  an  exception  to  the  statement  just  made,  Case  10,  a 
minister,  required  four  people  to  hold  him  in  bed  for  the  first 
10  or  15  minutes  following  his  operation. 

I  have  received,  February  20,  1896,  a  more  recent  and  care- 
ful description  of  the  arrangement  for  the  administration  of 
chloroform  and  oxj^gen. 

Dr.  Northrop  states  :  "It  gives  me  pleasure  to  make  known 
the  favor  with  which  chloroform  and  oxygen,  as  an  anaesthetic, 
has  been  received,  to  lay  down  a  few  exphcit  rules  for  its  ad- 
ministration and  to  now  describe  a  new  apparatus. 

"I  wish  to  publicly  thank  Dr.  J.  H.  McClelland,  of  Pittsburg, 


OXYGEN    WAS    AN    ANTIDOTE    TO    CHLOROFORM.       345 

for  the  unreserved  and  valuable  endorsement  he  has  given  this 
anaesthetic,  after  the  most  thorough  tests. 

"This  article  is  prompted  by  a  feeling  of  its  necessity  at  the 
present  time,  in  view  of  the  fact  that  frequent  inquiries  are 
made  of  me  in  regard  to  '  C.  &  0.'  apparatus.  The  apparatus 
can  now  be  bought  of  Charles  Lentz  &  Sons,  18  North  Eleventh 
Street,  Philadelphia,  and  has  received  my  final  approval." 

The  following,  Plate  48,  is  an  illustration  of  oxygenated 
chloroform  apparatus. 

Plate  48. 


"It  is  arranged  in  a  nicely  polished  wooden  box,  18  inches 
long,  7  inches  wide,  7  inches  deep,  contains  a  steel  cjdinder 
holding  40  gallons  of  pure  oxygen,  a  graduated  2-ounce  bottle, 
the  requisite  length  of  rubber  tubing  and  the  inhaler.  The 
latter  has  an  inflatable  face-shield  attached  to  a  metallic  hood, 
with  which  is  also  connected  a  rubber  respiratory  bag.  This, 
with  the  small  wheel  to  be  attached  to  the  cjdinder,  the  perfor- 
ated rubber  cork  and  nickel-plated  brass  tubes,  is  all  the  appa- 
ratus necessary  for  the  proper  administration  of  chloroform  and 
oxygen.     One  may  (and  should)  also  keep  in  his  C.  &  0.  box 

23 


346  ARTIFICIAL    ANESTHESIA. 

one  (or  two)  quarter-pound  cans  of  ether,  a  folding  Allis  ether 
inhaler,  a  hj^podermic  sj^ringe,  proper  stimulants,  a  pair  of  vul- 
sella forceps  and  an  infusion  apparatus.  A  mouth-gag  will  be 
added  to  the  above  list  by  those  who  desire  it.  The  apparatus 
weighs  19|  pounds. 

"In  order  to  use  the  apparatus  put  two  ounces  of  pure  chloro- 
form into  the  bottle,  attach  the  tubes  to  the  cylinder  and  per- 
forated cork,  and  place  the  bottle  in  the  corner  near  the  open 
end  of  the  box,  passing  the  tube  leading  to  the  inhaler  through 
this  opening.  Pull  out  the  cylinder  until  it  touches  the  bottle 
and  fix  it  in  position  by  tightening  the  screw  in  the  top  of  the 
iron  ring  supporting  the  cylinder.  Put  the  wheel  on  the  cylin- 
der valve,  close  and  fasten  the  lid  of  the  box,  and  the  apparatus 
is  ready. 

"It  is  my  custom  to  place  the  box  on  the  left  side  of  the 
patient,  upon  the  bed  or  operating  table,  or  upon  a  high  stool 
or  small  table,  if  its  position  beside  the  patient  would  interfere 
with  the  operation. 

"In  administering  the  anaesthetic  turn  the  wheel  carefully 
until  a  gentle  but  continuous  current  of  oxygen  bubbles  up 
through  the  chloroform,  and  apply  the  mask  directly  to  the 
patient's  face,  making  it  fit  tightly.  The  oxygenated  chloro- 
form vapor  at  this  stage  is  not  (should  not  be)  concentrated 
enough  to  disturb  the  equilibrium  of  the  patient's  respirations. 
All  anaesthetists  know  that  the  deeper  and  fuller  the  subject 
breathes  the  more  easily  and  rapidly  will  a  state  of  narcosis  be 
produced.  The  same  holds  good  when  employing  chloroform 
and  oxygen.  As  the  patient  approaches  the  unconscious  state 
turn  on  a  slightly  stronger  current  of  oxygen,  and  if  the  stage 
of  rigidity  ensue  (it  is  very  frequently  absent)  a  still  stronger 
current  should  be  used. 

"  It  is  sometimes  possible  to  begin  anaesthesia  with  a  moder- 
ately strong  current,  to  continue  the  same  until  complete  relax- 
ation is  produced,  and  this  without  causing  a  ripple  of  disturb- 
ance in  the  patient's  respiratory  or  cardiac  functions.  Several 
times  it  has  been  my  surprise  (and  pleasure)  to  find  my  patient 
completely  relaxed  and  ready  for  operation  while  I  was  waiting 
for  a  stage  of  rigidity. 


OXYGEN    WAS    AN    ANTIDOTE    TO    CHLOROFORM.       347 

"  I  have  found  that  complete  relaxation  and  puffing  breath- 
ing, which  are  characteristic  of  deep  anaesthesia,  prevail  at  first, 
even  though  the  cornea  be  not  insensitive.  The  latter  indica- 
tion of  the  full  anaesthetic  state  will  come  later;  but  do  not 
wait  for  it  before  notifying  the  operator  to  begin.  Continue 
the  inhalation,  and,  as  a  rule,  the  cornea  will  shortly  become 
ansesthetic.  I  say  as  a  rule,  for  sometimes  it  seems  impossible 
to  bring  about  its  in-sensitiveness.  Here  the  patient  is  usually 
a  male,  probably  an  alcoholic,  large,  muscular,  '  bull-necked. ' 
But  simply  having  a  sensitive  cornea  dees  not  mean  that  he  is 
not  ready  for  operation.  Experience  has  proved  that  he  is  and 
that  he  will  not  resist  surgical  interference. 

"Further  demands  for  0.  &  0.  are  made  in  the  same  way  as 
for  any  anaesthetic.  Eesistance  upon  the  part  of  the  patient, 
recurring  sensitiveness  of  the  cornea,  attempts  to  vomit,  etc., 
all  indicate  a  renewal  of  the  inhalations.  It  is  my  habit  to 
leave  the  inhaler  in  position,  even  though  the  current  be  turned 
off.  And  as  long  as  the  mixture  is  being  inhaled  I  watch  the 
cornea  and  pupil  particularly  and  feel  the  pulse  at  the  wrist  oc- 
casionally. The  wrist  is,  in  my  opinion,  the  only  place  to  satis- 
factorily test  the  heart's  action.  If  the  cornea  is  totally  insen- 
sitive, and  especially  if  the  pupil  is  enlarging,  turn  off  the 
oxygen.  Watch  for  the  return  of  the  sensitiveness  of  the  cor- 
nea, and  in  a  few  minutes  it  will  be  found.  Inhalations  need 
not  be  renewed  immediately,  however.  The  anaesthetist  must 
use  his  own  judgment  here,  and  at  all  times,  as  to  the  quantity 
of  the  anaesthetic  to  be  employed. 

"  Should  retching  occur  and  vomiting  threaten,  administer  a 
fairly  concentrated  vapor,  at  the  same  time  encouraging  the 
patient  to  breathe,  which  can  be  done  by  keeping  the  jaw  well 
raised.  This  will  be  found  effectual  in  bringing  about  relaxation 
of  the  diaphragm  and  abdominal  muscles. 

"  In  case  of  collapse  it  may  be  thought  advisable  to  remove 
the  long  rubber  tube  from  the  chloroform  bottle  and  attach  it 
to  the  cylinder  in  order  to  administer  pure  oxygen  to  the  col- 
lapsed subject.  It  will  perhaps  be  necessary  to  pull  out  the 
tongue  and  perform  artificial  respiration  at  the  same  time. 

"I  advise  each  possessor  of  a  C.  &  0.  apparatus  to  carry  a 


348  ARTIFICIAL    ANESTHESIA. 

piece  of  paper  in  the  box,  and  to  regularly  note  the  date  and 
length  of  operation,  thus  keeping  a  record  of  the  duration  of 
time  the  cylinder  is  used.  Let  him  also  number  each  cylinder 
upon  the  label  near  the  end,  and  so  be  able  to  determine  ap- 
proximately the  amount  of  oxygen  it  contains,  and  accordingly 
the  length  of  time  it  should  last,  I  have  found  a  cylinder  to 
furnish  oxygen  enough  for  from  four  to  six  hours  of  operating. 
•'  Let  me  again  caution  the  anaesthetist  not  to  waste  the  oxy- 
gen. When  not  desiring  to  make  the  patient  inhale  the  vapor, 
turn  off  the  current  completely,  even  though  the  inhaler  be  left 
in  position.  It  requires  but  the  slightest  turn  of  the  wheel  to 
furnish  a  current  of  the  proper  strength." 

Cliloroforin  and  Oxygen. 

The  most  recent  observations  in  regard  to  the  efl&ciency  of  the 
anaesthetics,  chloroform  and  oxygen,  Dr.  Northrop  reported  a 
few  months  ago,  and  Dr.  Hassler*  has  had  the  same  good  re- 
sults since  that  report.  The  number  of  cases  during  the  year, 
254  having  vomited  following  its  use  is  but  9.5  per  cent.,  occur- 
ring mostly  in  alcoholic  and  intestinal  operations.  The  shortest 
time  to  complete  anaesthesia  was  48  seconds,  and  the  longest  12 
minutes,  in  a  hysterical  woman.  The  smallest  amount  used 
was  three  drachms  in  seventy  minutes  for  the  operation  of  colo- 
totomy,  for  removal  of  both  ovaries.  Ether  has  been  given 
more  frequently  than  any  other  anaesthetic. 

The  same  authority  states  that  "chloroform  has  been  re- 
stricted to  children,  alcoholics  and  short  operations."  In  this 
year's  report  they  only  employed  nitrous  oxide  in  one  case. 

Upon  inquiry  among  the  surgeons  of  all  the  schools  in  Phil- 
adelphia I  find  but  only  one  or  two  who  have  employed  chloro- 
form and  oxygen  to  any  extent ;  indeed,  only  one.  Professor 
Montgomery  has  used  it  extensively  in  his  operations.  But  I 
find  they  all  have  it  at  hand  for  use  after  extensive  operations  in 
case  of  any  indication  of  very  weak  pulse  and  respiration. 

-;•;-  "^  Year's  Work  of  Ausestlietizing  370  Cases  in  Dr.  Northrop's 
Hospital,"  March,  1896. 


OXYGEN-INHALING    APPARATUS. 


349 


Oxygen-Tnlialing^  Apparatus. 

A  very  useful  apparatus  is  that  devised  bj"  the  S.  S.  White 
Co. ;  the  administration  is  absolutely  under  the  control  of  any 
intelligent  individual. 

Plate  49. 


The  inhalation  apparatus  will  be  seen  in  Plate  49,  and  is  a 
modification  of  the  nitrous  oxide  apparatus. 

A  represents  the  cylinder  filled  with  compressed  oxygen  gas 
into  a  liquid  ;  B,  the  gas  valve  ;  C,  a  rubber  bag  holding  three 
pints  ;   D,  a  wash-bottle  half  filled  with   water.      The  wash- 


350  ARTIFICIAL    ANAESTHESIA. 

bottle  serves  several  important  purposes  :  it  indicates  how  fast 
the  gas  is  flowing ;  it  also  calls  attention  if  the  valve  of  the 
cj'linder  be  not  closed  tightl}-;  arrests  an}^  dust  that  might  be 
carried  from  the  C3'linder,  or  from  the  interior  of  the  tubing 
or  bag  ;  and  moistens  the  gas,  thus  preventing  its  absorbing 
moisture  from  the  throat  and  air  passages.  At  E  is  a  mouth- 
piece attached  by  a  rubber  tube  to  the  bottle  ;  F,  a  rubber  tube 
connecting  rubber  bag  to  B  ;  and  G,  a  rubber  tube  connecting 
the  bag  with  the  wash-bottle  by  means  of  a  glass  tube  which 
extends  nearly  to  the  bottom  of  the  bottle.  In  using  the  appa- 
ratus arrange  the  parts  as  shown  in  the  Plate,  being  careful  to 
place  the  leather  wagher  properly  at  the  outlet  of  the  valve  (B), 
and  half  fill  the  bottle  (D)  with  water.  Open  the  valve  (B) 
very  slowly  and  cautiously ;  the  oxygen  will  then  flow  through 
the  tube  (F)  to  the  gas  bag  (C).  When  the  bag  is  fllled  the 
valve  (B)  may  be  closed  and  the  apparatus  is  ready  for  use.  If 
the  valve  (B)  is  open  too  much  a  portion  of  the  gas  may  rush  by 
the  bag,  and  forcing  its  way  through  the  water  be  lost ;  to  correct 
this  it  is  only  necessary  to  partially  close  valve  (B).  In  adminis- 
tering oxygen  by  the  lungs  the  usual  practice  is  to  cause  the 
patient  to  inhale  very  slowly  from  three  to  four  gallons,  say 
twice  a  day,  taking  it  into  the  mouth  through  the  glass  tube, 
breathing  at  the  same  time  through  the  nostrils.  The  gas 
should  be  retained  in  the  lungs  as  long  as  possible,  as  more  than 
this  quantity  may  do  harm.  In  severe  cases  of  dyspnoea, 
asthma,  croup,  diphtheria  or  pneumonia  much  larger  quantities 
may  be  required,  as  in  a  case  of  the  latter  disease,  reported  by 
Dr.  Albert  X.  Blodgett  (Boston  Medical  and  Surgical  Journal, 
November  20,  1890),  which  gives  a  record  from  his  note  book, 
as  follows  : 

The  patient  was  "in  articulo  mortis."  Oxygen  inhalations 
had  been  employed  at  intervals  during  the  progress  of  the  case, 
always  with  relief  to  the  patient.  He  now  directed  that  the 
administration  of  the  gas  be  made  continuous,  not  with  any 
hope  of  curing,  for  he  states  that  he  was  under  the  positive 
conviction  that  the  patient  was  irrevocably  doomed  :  the  best 
result  he  looked  for  being  simply  relief  to  the  sensation  of  suflfo- 
cation.     The  gas  was  conveyed  from  the  tank  in  which  it  was 


MIXED    ANAESTHETICS.  351 

supplied  through  a  wash-bottle  directly  to  the  mouth  of  the 
patient,  and  a  constant  stream  of  gas  was  flowing  through  the 
tube  all  the  time,  so  that  with  each  of  the  rapid  inspirations 
the  patient  was  obtaining  a  constantly  increased  amount  of 
oxygen.  This  was  continued  for  lOG  hours,  the  quantity  of  gas 
emploj-ed  being  not  far  from  two  hundred  gallons  in  twentj^-four 
hours.  The  patient  having  then  progressed  far  enough  toward 
convalescence  to  warrant  it,  the  oxygen  inhalations  were  discon- 
tinued. The  patient  was  eventually  restored  to  her  previous 
condition  of  health.  Commenting  on  the  case,  Dr.  Blodgett 
said: 

"  I  feel  that  in  extreme  dyspnoea  or  in  threatened  asphj^xia 
we  have  in  this  agent  the  means  of  obtaining  in  many  cases  a 
distinct  relief  of  the  suffering,  and  a  painless,  if  inevitable, 
death." 


CHAPTER    XII. 


Mixed  Anaesthetics. 


The  various  mixtures  of  ansesthetics  first  received  their  im- 
pulse from  the  report  of  the  Chloroform  Committee  of  the 
Medical  Chirurgical  Society  of  London,  who  declared  their  su- 
periority in  point  of  safety.  M.  Perrin  gives  an  account  of  the 
first  death,  known  at  that  time  to  have  taken  place  under  a 
given  mixture  of  ether  and  chloroform,  and  gives  the  credit  to 
the  chloroform  as  being  improperly  administered,  and  Snow 
says  the  patient  died  of  haemorrhage  ;  but  our  reading  of  the 
case,  carefully  reported  by  Dr.  R.  Crockett,*  leaves  the  decided 
impression  that  chloroform  arrested  the  heart's  action,  inducing 
vomiting,  and  caused  a  stoppage  of  the  respiration.  The  fol- 
lowing is  an  abstract  of  the  important  facts  in  the  case,  and  is 
interesting  as  the  first  death  from  the  mixture:   "A  sprightly 

*  Am.  Jour.  Med.  Sci.,  July,  1857,  pp.  284-5. 


352  ARTIFICIAL    ANESTHESIA. 

little  bo3%  five  years  of  age,  was  brought  to  the  doctor  to  have  a 
fattj'-  tumor  removed  from  his  back.  The  tumor,  commencing 
at  a  point  at  its  inferior  termination,  opposite  the  last  rib,  about 
two  and  a  half  inches  to  the  right  of  the  spinous  processes,  and 
extending  obliquely  upwards,  crossing  the  spine  seven  inches, 
required  two  elliptical  incisions,  nine  inches  long,  for  its  re- 
moval." The  operation  was  commenced  at  9.30  A.M.,  April 
4th,  and  the  dissection  was  rapidly  executed,  stopping  to  ligate 
a  large  artery  that  was  earlj^  divided ;  the  remaining  arteries 
were  compressed  as  they  were  divided.  The  tumor  was  quickly 
removed  and  a  ligature  applied  to  the  last  artery,  being  the 
sixth  in  number.  While  sponging  the  wound  the  boy  began  to 
vomit,  and  on  examining  the  wrist  he  was  found  to  be  pulseless. 
Dr.  K.,  who  had  charge  of  the  anaesthetic  and  pulse,  replied 
that  "the  pulse  had  never  given  way  until  he  began  to  vomit." 
He  ejected  a  small  portion  of  the  contents  of  the  stomach.  He 
was  immediately  placed  in  the  "prone  position,"  as  recom- 
mended by  Dr.  Marshall  Hall.  The  finger  was  introduced  into 
the  mouth  to  be  certain  that  the  tongue  had  not  fallen  back  so 
as  to  obstruct  the  glottis,  or  the  entrance  of  air  into  the  wind- 
pipe, and  the  extremities  were  rubbed  with  aqua  ammonia. 
The  patient  died  three  or  four  minutes  from  the  commencement 
of  the  vomiting.  "He  lost  probably  four  ounces  of  blood; 
certainly  not  exceeding  six."  There  was  no  post-mortem  ex- 
amination. 

The  anaesthetic  used  was  a  mixture  of  washed  ether,  four 
parts,  and  one  of  chloroform,  obtained  from  the  late  Frederick 
Brown,  of  Philadelphia,  w^hose  character  is  a  sufiicient  guaran- 
tee that  they  were  pure.  Everj^  preparation  for  the  operation 
having  been  made,  the  administration  of  the  ana3sthetic  was 
commenced  by  Dr.  Crockett,  observing  all  the  precautions  so 
fully  recommended  by  Erichsen,  p.  78,  of  his  "  Operative  Sur- 
gery." As  soon  as  anaesthesia  was  induced,  the  sponge  was 
confided  to  Dr.  Kincannon,  who  held  his  finger  all  the  while  on 
the  patient's  pulse.  The  doctor  concludes,  "  I  have  lately  em- 
ployed this  anaesthetic  freely,  formerly  having  used  ether  alone. 
As  yet  I  have  not  seen  a  case  of  death  reported  fro'ni  ether ^  or 
this  mixture  of  it  with  chloroform,  that  I  can  now  recollect. 


MIXED    ANAESTHETICS.  353 

Are  there  any  such  reported  ?  I  fear  all  the  deaths  from  anaes- 
thesia are  not  reported."  Five  deaths  from  the  use  of  this 
mixture  have  been  published. 

The  chief  object  of  these  anaesthetic  mixtures  is  the  avoid- 
ance of  the  danger  from  sJwch,  or  from  the  depressing  influence 
upon  the  heart-action,  which  chloroform  most  certainly  exerts, 
and  which  ether  and  alcohol  prevent.     The  committee  before 

referred  to  proposed  the  following  mixtures  : 

Parts. 

A.  Alcohol, 1 

Chloroform, 2 

Ether, 3 

B.  Chloroform, 1 

Ether, 4 

C.  Chloroform, 1 

Ether, 2 

Dr.  Sansom's  mixture*  is  equal  parts  by  measure  of  chloro- 
form and  absolute  alcohol.  The  introduction  of  alcohol,  which 
plays  an  important  part  in  the  mixture,  was,  according  to  the 
doctor,  due  to  Dr.  Harley.  The  committee  says  it  is  by  "  the 
uniform  blending  of  the  ether  and  chloroform,  when  combined 
with  alcohol,  and  probably  the  more  equable  escape  of  the  con- 
stituents in  vapor."  The  chloroform  is  the  potent  agent,  and 
the  others  chiefly  coadjutors,  vehicles  and  diluents  of  the  chlo- 
roform. 

Dr.  Sansom  gives  the  following  testimony  as  to  the  stimu- 
lating eff"ects  of  alcohol  in  counteracting  the  depressing  influ- 
ence of  chloroform  :  "  In  my  own  experiments  I  have  found 
that  alcohol  has  had  the  greatest  eff"ect  in  sustaining  the  heart- 
action  during  the  influence  of  the  chloroform.  I  can  particu- 
larly recollect  one  instance,  in  which  alcohol  was  administered 
in  vapor  to  a  frog,  after  it  was  impossible  to  cause  death  by  any 
strength  of  chloroform  vapor."  In  recommending  this  mix- 
ture before  the  Obstetrical  Society  of  London,  Dr.  Sansom  went 
one  step  farther,  and  stated  that  this  mixture  gives  off"  a  pro- 
portion of  chloroform  vapor  in  a   given   time   almost  exactly 

*  Chloroform  :  Its  Action  and  Administratiou.  By  Arthur  Sansom, 
M.B.,  London. 


354  ARTIFICIAL    ANESTHESIA. 

half  of  that  which  is  given  off  by  chloroform  pure  and  sim- 
ple. The  result  is  not  confirmed  by  any  experiment  of  his 
published . 

What  are  the  ohjections  to  ancesthetic  "mixtures  9 

1.  The  length  of  time  required  for  the  production  of  complete 
anaesthesia.  2.  The  probability  of  entire  sensibility  not  being 
abolished.  3.  The  unequal  rate  of  evaporation  or  vaporization 
of  the  fluids. 

There  is  not  any  doubt  but  that  the  process  is  slower  and  at- 
tended with  more  excitement  by  the  mixed  fluids  than  by  chlo- 
roform alone.  The  second  objection  cannot  be  sustained.  The 
third  is  the  "element  of  danger."  It  was  flrst  advanced  by 
Snow.  He  says:  "When  ether  is  combined  with  chloroform, 
the  result  is  a  combination  of  the  undesirable  qualities  of  both 
agents,  without  any  compensating  advantage,"  and  the  danger 
is  because  the  operator,  toward  the  end  of  the  process,  may  be 
giving  a  pure  chloroform  when  he  thinks  he  is  giving  the 
weaker  mixture  of  vapors.  Dr.  Ellis  endeavored  to  prove  this, 
and  states  :  ' '  Out  of  the  six  or  seven  minutes  occupied  by  the 
evaporation  of  the  half-drachm  of  fluid,  the  first  was  occupied 
chiefly  by  the  ether,  the  next  three  by  the  chloroform  with  a 
little  alcohol,  and  the  last  by  the  alcohol  alone.  In  an  inhaler, 
the  patient  would  have  breathed,  for  one-fifth  of  the  time, 
chiefly  the  vapor  of  ether  ;  for  the  next  three-fifths,  that  of 
chloroform,  with  a  little  alcohol;  and  at  last,  only  the  vapor  of 
a  minute  quantity  of  alcohol."  These  results  are  not  stated  as 
obtained  by  actual  experiments,  and  they  depend,  first,  upon 
the  purity  of  the  agents  employed ;  second,  upon  the  boiling- 
point,  which  has  a  great  influence  upon  the  results,  for  the 
more  volatile  the  fluid,  the  greater  will  be  the  variation. 
We  here  give  the  boiling-point  of  the  most  important  anaes- 
thetics. 

The  temperature  which  is  constant  for  the  same  substance, 
under  the  same  atmospheric  pressure,  is  called  the  hoiling- 
point 

The  following  are  the  agents  employed  as  anaesthetics  in  the 
form  of  vapor,  the  boiling-points  being  given  for  the  mean 
pressure  of  760  millimeters  : 


MIXED    ANAESTHETICS.  355 

Protoxide  of  nitrogen, 88° 

Carbonic  acid, 78° 

Chloride  of  etlij'l  v.  pure  ether,         ....  11° 

Ether, 35° 

Chloroform 63° 

Alcohol, 78° 

Oil  of  turpentine, 157° 

A  difference  of  pressure  of  0.25  centimeter  will  cause  a  dif- 
ference in  the  boiling  of  water  one-tenth  of  a  degree.  The 
boiling-point  is  also  influenced  by  dissolving  in  a  fluid  a  sub- 
stance more  volatile  than  itself  (as  ether  and  chloroform) ;  it 
increases  the  boiling-point  in  proportion  to  the  amount  dis- 
solved. The  temperature  of  the  atmosphere  has  a  powerful 
influence  on  these  volatile  agents,  as  it  is  a  well-known  chemical 
fact  that  the  saturation  of  the  air  increases  vastl}^  with  the  in- 
crease of  temperature,  and  the  capacity  of  the  air  for  aqueous 
vapor  is  doubled  with  each  27°  of  temperature,  Fahrenheit. 
Sulphuric  ether  at  60°  F.  and  thirty  inches  of  the  barometer 
expands  two  parts  of  the  air  into  three,  and  forms,  therefore, 
at  that  temperature  and  pressure,  one-third  of  the  air  inhaled 
into  the  lungs  of  a  patient.  Under  the  same  circumstances, 
chloroform  expands  fourteen  parts  of  air  into  fifteen,  and  con- 
sequently the  vapor  of  chloroform  constitutes  one-fifteenth  part 
of  the  air  inhaled. 

The  following  experiments  were  made  October  30,  1878,  so 
as  to  determine  the  time  required  for  each  of  the  agents  to 
evaporate  on  a  given  surface  of  tissue-paper,  suspended  in  the 
air  at  a  temperature  of  70°  F. ,  one  drop  of  each  being  carefully 
measured  by  the  same  dropping  machine.  The  time  was  accu- 
rately kept  by  Dr.  C.  S.  Turnbull,  son  of  the  writer,  and  the 
results  served  to  confirm  the  rough  experiments  made  before 
the  Dental  Convention  at  Washington,  D.  C,  on  October  10, 
1878,  and  proved  the  facts  stated  in  the  author's  first  edition  of 
this  work.  We  have  always  found  that  when  such  a  mixture 
was  poured  upon  the  inhaler,  the  most  volatile  spirit  would  rise 
first,  then  the  next,  and  so  on,  leaving  the  least  easily  evapo- 
rated upon  the  inhaler.  Another  important  fact  was  proven, 
and  which  was  before  referred  to,  that  the  alcohol  employed  in 


356 


ARTIFICIAL    ANESTHESIA. 


the  mixtures  with  chloroform  in  England,  also  the  ethers  made 
from  such  alcohols,  are  much  inferior  to  those  made  in  this 
country  from  grain,  not  from  wood,  potatoes  or  other  agents. 
I  regret  to  state  this  is  no  longer  the  case.  These  latter  are 
slow  in  evaporation,  and  are  mixtures  themselves,  containing  a 
large  amount  of  carbonaceous  products. 

The  following  are  the  results  obtained,  after  numerous  ex- 
periments, by  the  author,  with  as  many  of  the  agents  employed 
in  the  various  mixtures,  and  obtained  from  the  reliable  estab- 
lishments of  Powers  &  Weightman,  Bullock 
Wyeth  &  Bro. ,  and  J.  P.  Remington  : 


Alcoliol,  absolute  95  (W.  &  Bro.), 
Alcohol,  common  (W.  &  Bro.), 
Chloroform  (P.  &  W.),    . 
Ether  (Squibb's),     . 
Ether,  common,  0.750  (P.  &  W.), 
Ether,  Hydrobromic  (R), 
Methylic  alcohol  (B.  &  C),    . 
Potato  spirit,*-  (B.  &  C), 
Temperature,  70  F. 
Barometer,  30.08. 
Time,  2  p.m. 


Danger  from  the  Water  Produced  from  Ether. 

Besides  the  danger  from  inhaling  the  ether  pure  and  simple, 
there  is  another  to  be  prevented  ;  that  is,  to  get  rid  of  the 
watery  vapor  from  the  mixture  and  also  from  the  lungs  of  the 
patient,  which  collects  on  the  sponge.  If  the  napkin  or  inhaler 
is  too  close  to  the  patient's  mouth  and  nose,  it  will  most  effectu- 
ally prevent  air  from  reaching  the  lungs.  How  is  this  to  be 
prevented?  By  squeezing  out  the  sponge,  napkin,  lint,  or  if 
an  inhaler  is  employed  that  cannot  thus  be  treated,  casting  it 
aside,  and  taking  a  clean  napkin,  with  as  much  starch  in  it  as 
possible,  so  as  to  keep  it  in  shape. 

It  has  been  well  observed  by  Perrin  :  "We  believe  we  shall 
render  a  veritable  service  if  we  popularize  the  idea  that  anaes- 


&  Crenshaw, 

Min. 

Sec. 

1 

24 

10 

00 

00 

24 

00 

12 

00 

24 

00 

12 

.  1 

00 

.  12 

00 

Passed  through  charcoal  by  W.  &  Bro. 


BRIEF    EXTRACT    OF    EXPERIMENTS.  357 

thesia  should  be  observed  and  studied  at  the  hospital  with 
as  much  care  as  every  other  subject  of  practical  medicine." 
Sansom  also  says:  "  The  administrator  should  be  experienced. 
Several  hospital  committees  have  acted  wisely  in  appointing  a 
chloroformist,  a  measure  which  is  not  of  less  value  to  the  oper- 
ating surgeon  than  it  is  to  the  benefit  of  the  patient.  One  who 
administers  chloroform  in  any  case  should  confine  himself  exclu- 
sively to  the  task  he  has  undertaken,  and  should  constantly 
mark  the  symptoms."  What  are  the  sj^mptoms  of  danger? 
The  failure  of  the  pulse,  irregularity  of  the  respiration,  and  the 
blanched  countenance,  and,  as  beautifully  expressed  by  an  old 
writer  in  reference  to  successful  administration  of  anaesthetics : 
"  Proceed  steadily  but  cautiously  to  the  end  in  view.  He  who 
makes  haste  slowly,  and  with  a  boldness  tempered  by  wisdom,, 
carries  his  patient  down  into  the  dark  valley  which  borders  on 
death,  drowns  human  agonies  in  the  waters  of  Lethe,  and  tri- 
umphs in  the  crowning  glory  of  his  art. 

The  Inlialation  of  Cliloroform  and  Ether  a  Cause 
of  Aural  Disease. 

Cases  of  deafness  are  reported  by  Dr.  Charles  E.  Hackey,  of 
New  York,  as  having  followed  the  inhalation  of  chloroform 
for  complete  narcosis  for  surgical  operations. 

Dr.  D.  B.  St.  John  Roosa,  of  New  York,  has  also  published 
that  several  cases  of  tinnitus  aurium  and  loss  of  hearing  have 
come  under  his  observation,  which  were  said  to  have  been 
caused  by  the  inhalation  of  ether  for  the  purposes  of  anaesthesia. 
No  such  results  have  followed  in  our  use  of  anaesthetics. 

Brief  Extract  of  Experiments  with  a  Mixtiu'e  of 

Ether  and  Bromide  of  Ethyl  and  Chloroform 

Performed   hy    Drs.    Reichert,    Turnhull 

and  Thomas,  May  6,  1885. 

Experiments  were  performed  first  upon  a  rabbit,  then  upon 
a  dog.  In  the  first  instance  a  mixture  of  ether  and  bromide  of 
ethyl  (.lij  to  Oj)  was  applied,  and  the  animal  prepared  by  in- 
serting a  tube,  to  which  a  pulse  indicator  was  attached,  into  the 


358  ARTIFICIAL    ANESTHESIA. 

carotid  artery,  thereby  showing  the  regular  action  of  the  heart. 
The  trachea  was  opened  and  a  tube  appKed. 

The  nasal  branch  of  the  fifth  pair  of  nerves  was  irritated, 
and  inhibition  of  the  heart's  action  was  immediately  shown,  and 
when  repeated  cessation  was  almost  produced.  The  animal  was 
allowed  to  recover,  after  which  it  was  proposed  to  apply  chloro- 
form and  repeat  the  test  ;  but  almost  simultaneously  with  the 
application  of  the  chloroform  the  heart's  action  ceased  entirely, 
showing  the  dangerous  character  of  that  agent  as  an  anaesthetic. 

The  post-mortem  showed  the  lungs  to  be  in  a  normal  condi- 
tion, as  were  also  all  the  organs  except  the  liver,  which  was 
badly  tuberculous,  a  condition  frequently  found  in  the  rabbit. 
A  perceptible  heart-motion  continued  for  some  time  after  death, 
but  with  insufficient  force  to  propel  the  blood,  the  indicator 
remaining  perfectly  quiet. 

In  the  second  instance  ether  was  applied  to  the  dog  with  sim- 
ilar preparation  as  the  rabbit,  and  with  like  result,  after  which 
he  was  injected  with  chloral,  and  a  current  of  electricity  was 
applied  to  the  laryngeal  branch  of  the  pneumogastric  nerve. 
The  effect  upon  the  heart  was  instantaneous  to  such  an  extent 
as  to  cause  complete  suspension  of  the  pulsation.  The  result 
was  the  same  when  the  current  was  applied  to  the  pneumogastric, 
the  continuance  of  which  must  have  produced  death. 

Mixed  Ansestlietics. 

According  to  Dr.  Wood  it  is  probable  that  many  of  the  diffi- 
culties which  attend  the  use  of  ether  can  be  overcome  by  put- 
ting in  the  inhaler,  or  the  sponge,  ethyl  bromide  and  then  ether, 
the  patient  passing  insensibly  from  the  bromide  narcosis  into 
that  of  the  ether. 

We  prefer  much  better  the  plan  to  commence  anaesthetization 
with  nitrous  oxide  to  be  followed  with  ether,  and  which  is  em- 
ployed by  a  few  surgeons  of  this  country.  If  the  statistics 
which  we  give  from  St.  Bartholomew's  Hospital  for  this  com- 
bination can  be  depended  upon,  in  which  12,941  anaesthetiza- 
tions  were  given,  there  being  but  one  death,  this  is  one  of  the 
most  conclusive  proofs  to  our  mind  of  narcotic  anaesthetic  prop- 


DR.  w.  atlee's  mixture.  359 

erties  of  nitrous  oxide  as  not  simply'  an  asph3^xiant  that  we 
have  a  record  of. 

A  second  death  was  reported  in  the  London  Lancet^  1896,  of 
an  individual  under  nitrous  oxide  and  ether. 

Dr.  W.  Atlee's  Mixture. 

It  maj"  again  be  inquired  which  is  the  best  mixture  to  employ 
in  ordinar}^  surgical  operations  when  it  is  absolutel}^  necessary 
to  employ  such  mixtures.  The  mixture  C  in  midwifery.  Mix- 
ture A,  or,  as  it  is  familiarly  known,  A.-C.-E.  or  "  ace-of-spades 
mixture,"  the  most  agreeable  of  all.  In  the  operation  for  ovari- 
otomy we  prefer  the  C  mixture,  as  also  advised  by  the  late  Dr. 
Washington  Atlee  ;  the  volumes  of  the  two  agents  are  so  dif- 
ferent that  they  ought  to  be  mixed  b.y  weight,  not  by  measure, 
else  chloroform  will  be  much  in  excess,  as  it  is  a  little  over  twice 
the  weight  of  ether.  In  employing  alcohol  it  should  be  as  near 
to  absolute  as  possible,  and  free  from  any  color,  smell  or  taste. 
The  ether  should  be  almost  anhydrous,  pure,  full  strength,  and 
well  washed. 

The  late  Dr.  Atlee  was  of  the  opinion  (which  has  been  con- 
firmed) that  there  is  a  chemical  union  of  the  ether  and  chloro- 
form, for  it  has  been  found  that,  if  this  mixture  was  exposed 
to  the  light,  a  change  took  place  which  rendered  the  mixture 
not  fit  for  the  purposes  of  inhalation ;  it,  therefore,  should  be 
kept  from  the  light,  and  mixed  just  before  being  emploj^ed. 

Perfectly  dry  chloroform  decomposes  but  slowly,  even  in 
direct  sunlight ;  but  the  presence  of  water,  which  always  exists 
in  alcohol  and  ether,  and  the  action  of  light  at  the  same  time, 
causes  chloroform  to  decompose  into  formic  and  hydrochloric 
acids.     CHCI3  4-  2H,0  =  CH2O2  +  3HCL. 

We  have  had  charge  of  the  anaesthetic  mixture  (one  part  by 
measure  of  chloroform  and  two  of  washed  ether)  in  an  opera- 
tion by  the  late  Dr.  Washington  Atlee,  during  the  successful 
removal  of  an  ovarian  tumor  weighing  forty  pounds,  and  have 
also  assisted  him  in  three  cases,  in  which  others  gave  this  same 
mixture,  with  good  results,  and  with  no  apparent  risk  to  the 
safety  of  the  patient. 

Dr.  Atlee  always  administered  the  anassthetic  after  the  patient 
was  upon  the  operatirig  table,  and  one  individual  had  charge  of 


360  ARTIFICIAL    ANyESTHESIA. 

and  was  responsible  for  it.     In  his  three  hundred  ovariotomies, 
he  informed  me  he  had  never  lost  a  patient  by  the  anaesthetic. 

The  mixture  is  given,  in  almost  ever}^  instance,  by  means  of 
the  starched  towel. 

The  following  experiments  were  made  to  determine  the  ac- 
tion of  ether  and  chloroform  when  mixed  :  When  ether  and 
chloroform  are  mixed  there  is  an  elevation  of  temperature,  and 
the  greatest  heat  is  produced  when  the  mixture  is  made  in 
equivalent  parts  ;  that  is,  by  weight,  about  nine  and  one-quar- 
ter parts  of  ether  to  thirteen  and  one-quarter  parts  of  chloro- 
form. As  the  chloroform  is  more  than  twice  as  heavy  as  ether, 
the  volumes  would  be  about  one  and  four-tenths  chloroform  to 
two  of  ether.  But  little  contraction  in  volume  takes  place,  and 
it  may  be  considered  that  molecular  combination  takes  place 
between  the  chloroform  and  ether.  The  mixture  begins  to  boil 
at  50°  to  51°  C,  and  may  be  separated  into  its  constituents  by 
fractional  distillation ;  but  when  allowed  to  evaporate  sponta- 
neously, as  when  used  as  an  anaesthetic,  both  liquids  pass  into 
vapor  simultaneously. 

Whatever  mixture  is  employed,  nothing  will  obviate  the 
necessity  of  care  in  the  administration,  and,  above  all,  do  not 
give  more  of  the  agent  than  is  absolutely  necessary  to  keep  the 
patient  free  from  pain  ;  not  one  drop  more ;  for,  like  all  patent 
medicines  which  we  employ,  an  excessive  dose  is  sure  to  kill, 
and  unless  we  have  before  gauged  the  patient's  powers,  let 
caution  be  our  guide  in  the  administration  of  so  powerful  an 
anaesthetic.  In  our  anxiety  to  see  the  various  steps  of  an  ope- 
ration, we  must  not  saturate  the  sponge  or  lean  over  the  patient, 
and  by  accident  suffocate  him.  It  is,  unfortunately,  too  much 
the  practice  to  entrust  the  inhaling  apparatus  to  some  inexperi- 
enced hand,  who,  perhaps,  never  before  administered  an  anaes- 
thetic, and  even  in  some  hospitals  to  the  youngest  assistant 
surgeon  or  dresser. 

An  Albstract  of  the  Reports  of  Kecent  Deaths  from 
a  Mixture  of  Ether  and  Chloroform. 

The  death  of  a  lady  had  occurred  in  the  practice  of  Dr. 
Eastham,  a  dentist  of  Boston,  causing  much  excitement  in 
professional  circles.     The  death  had  taken  place  about  noon, 


REPORTS  OF  RECENT  DEATHS.        361 

but  very  few,  except  those  particularly  interested,  were  aware 
of  it  till  the  next  day.  The  coroner,  Dr.  Ainsworth,  who  was 
called  in  directly  after  the  accident,  formed  a  jury  of  physicians 
and  apothecaries,  and  ordered  an  autopsy.  This  was  made  the 
next  morning  by  Dr.  R.  H.  Fitz,  pathologist  to  the  Massachu- 
setts General  Hospital,  and  on  the  same  day  the  jury  met  and, 
having  viewed  the  body,  adjourned  until  the  14th.  The  anaes- 
thetic was  either  chloroform  or  a  mixture  of  chloroform  and 
ether.  The  latter  proved  to  be  the  one  used.  The  jury  met 
again  on  the  14th,  and,  having  heard  a  part  of  the  evidence, 
readjourned  till  the  evening  of  Wednesday  the  19th.  Instead 
of  death  resulting  from  ether,  it  was,  as  proved  by  the  analysis, 
due  to  chloroform^  and  the  coroner's  jury  presented  the  follow- 
ing verdict:  "Death  was  caused  by  the  inhalation  of  chloro- 
form, administered  in  a  mixture  of  chloroform  and  ether." 

Dr.  Henry  Buren,  of  Chicago,^  gives  the  following  version 
of  a  death  which  took  place  in  that  city  from  the  inhalation  of 
a  mixture  of  ether  and  chloroform  : 

"3Irs.  B. ,  aged  32,  American,  had  suffered  from  fistulse  in 
ano  for  six  months.  On  the  22d  of  November  last  I  operated 
on  her,  finding  at  this  time  two  artificial  openings  into  the  rec- 
tum, one  on  either  side  of  the  anus.  Dr.  A.  Groesbeck  admin- 
istered the  anaesthetic,  which  consisted  of  equal  parts  of  sul- 
phuric ether  and  chloroform.  The  operation  was  performed  in 
a  few  seconds.  The  patient  exhibited  no  alarming  symptoms 
while  under  the  influence  of  the  anaesthetic,  and  revived  in  the 
usual  time. 

"  On  the  morning  of  the  30th  of  November,  eight  days  after 
the  operation,  I  desired  to  make  a  thorough  examination  of 
the  wounds  and  renew  the  dressing,  and  in  this,  as  in  some  of 
the  previous  dressings,  the  patient  insisted  upon  partial  immu- 
nity from  pain.  To  this  end  I  commenced  to  administer  upon 
a  napkin  two  parts  of  sulphuric  ether  and  one  of  chloroform. 
After  a  few  inhalations  the  patient  became  violently  intoxi- 
cated, and  resisted,  with  great  force,  all  efforts  to  quiet  her,  de- 
manding, in  the  language  of  one  in  delirium,  to  be  let  alone. 

*  Chicago  Medical  Journal,  February,  1878. 
24 


362  ARTIFICIAL    ANESTHESIA. 

I  immediately  ceased  to  administer  the  anaesthetic,  and  with 
great  effort  prevented  her  from  jumping  from  the  bed.  The 
face  became  at  first  turgid,  the  whole  body  convulsive,  and  in 
a  few  seconds  the  patient  was  dead. 

"All  of  the  means  usually  resorted  to  were  employed  to  re- 
store action  of  the  vital  functions  ;  artificial  respiration,  ele- 
vating the  lower  extremities,  dashing  cold  water  in  the  face, 
drawing  forward  the  tongue,  spirits  of  ammonia  applied  to  the 
nostrils,  and  finally  a  galvanic  battery,  which  was  conveniently 
at  hand,  but  to  no  avail. 

"I  have  to  say,  in  justice  to  the  record  of  this  case,  that  the 
patient  had  for  many  years  habitually  partaken  of  opium.  At 
the  time  of  her  unfortunate  death  she  could  take  at  each  dose 
from  two  to  three  grains  of  morphia.  During  the  time  she  was 
under  my  care  one-half  grain  doses  of  morphia  were  prescribed 
at  proper  intervals,  but  she  asserted  that  this  quantity  did  not 
sufficiently  support  her,  and  through  her  nurse,  and  by  stealth, 
she  secured  additional  quantities  from  the  neighboring  drug 
stores,  and  took  the  same  daily  without  my  knowledge  or  con- 
sent. 

"  I  am  now  of  the  opinion  that  the  patient  had  taken  an  un- 
usually large  dose  of  morphia  on  the  morning  of  her  death,  and 
that  the  combined  influence  of  this  overdose  and  the  additional 
paralyzing  effects  of  the  anaesthetic  caused  cardiac  syncope,  and 
that  this  was  the  cause  of  death. 

"A  woman,  aged  46,  extremely  fat,  and  of  slow  intelligence, 
although  having  complained  of  shortness  of  breath,  was  not 
known  to  be  the  subject  of  organic  heart  disease.  She  was  to 
be  operated  upon  for  senile  cataract.  A  mixture  of  chloroform 
and  ether,  in  a  modified  Clover's  apparatus,  was  being  admin- 
istered by  the  house  surgeon.  From  the  commencement  of  the 
administration  respiration  was  noticed  to  be  shallow,  but  there 
was  struggling.  The  pulse  was  feeble,  but  not  intermittent. 
There  was  some  slight  lividity  of  cheeks  and  forehead.  Chlo- 
roform was  at  once  removed  and  a  few  whiffs  of  pure  ether 
administered  as  a  stimulant.  Other  means  for  circulation  were 
tried,  but  in  vain  ;  the  patient  died.  At  the  post-mortem  ex- 
amination the  heart  was  found  flaccid  and  empty,  the  mitral 


REPORTS  OF  RECENT  DEATHS.         363 

valve  was  contracted,  the  aortic  valves  were  incompetent,  kid- 
neys fatt}"  and  granular.* 

"In  the  spring  of  1865,  while  stationed  at  the  U.  S.  A. 
'  Summit '  House  General  Hospital,  Philadelphia,  the  staff 
were  performing  an  amputation  of  the  leg.  At  the  suggestion 
of  Surgeon  Joseph  Taj'lor,  in  charge,  the  A.  C.  E.  mixture  was 
used.f  The  anaesthetic  was  administered  b}"  Surgeon  A.  A. 
Leavitt,  executive  officer  of  the  hospital.  During  the  opera- 
tion the  patient's  respiration  failed.  The  condition  became  so 
alarming  that  the  operation  was  temporarily  discontinued,  and 
all  present  turned  their  attention  to  restoring  the  patient. 
Artificial  respiration,  cutaneous  excitation  and  inhalation  of 
fumes  of  ammonia,  fortunatelj',  were  successful.  The  opera- 
tion was  then  finished,  with  the  patient  only  partially  uncon- 
scious. For  many  years  I  had  not  used  this  mixture,  using 
either  ether  alone,  or  the  mixture  of  ether  two  parts,  chloro- 
form one  part,  by  weight ;  or,  rarely,  chloroform  alone. 

"During  the  past  two  years  I  have,  on  several  occasions,  used 
the  A.  C.  E.  mixture  with  gratifying  results,  being  led  to  use  it 
again  by  the  favorable  reports  given  by  various  authorities. 
During  the  summer  of  1886  I  was  removing  cancerous  mam- 
mary and  axillary  glands,  assisted  by  Drs.  Martin  and  Chesney, 
of  Cairo,  West  Virginia.  To  Dr.  Chesney  was  intrusted  the 
administration  of  the  anassthetic,  which  was  the  A.  C.  E.  mix- 
ture. During  the  operation  I  had  requested  him  to  discontinue 
the  anaesthetic,  as  the  patient  was  sufficiently  under  the  influ- 
ence. This  he  did  ;  he  had  his  finger  on  the  pulse,  and  devoted 
his  entire  attention  to  the  patient's  condition.  The  mammary 
gland  had  been  removed,  care  being  taken  by  Dr.  Martin  to 
prevent  entrance  of  air  into  the  veins.  I  noticed  the  extreme 
pallor  of  the  patient's  face,  and  simultaneously  Dr.  Chesney 
said  the  pulse  had  failed,  so  as  to  be  inappreciable.  I  imme- 
diately placed  a  bottle  of  nitrite  of  amyl  to  her  nostrils  ;  respi- 
ration was  good.  Asking  Dr.  Martin  to  hold  it  there,  I 
prepared  a  hypodermatic  syringe  with  20  m.  of  tr.  digitalis,  and 
injected  it  into  the  prsecordial  region.     Dr.  Martin  meantime 

*  Med.  Times  and  Gazette,  August  18,  1876. 

t  W.  H.  Sharpe,  M.D.,  Medical  News,  March  5,  1887,  p.  257. 


364  ARTIFICIAL    ANiESTHESIA. 

announced  a  slight  recovery  of  pulse.  I  next  administered 
several  sj^ingefuls  (hypodermatically)  of  whiskey,  and  we  had 
the  pleasure  of  seeing  the  patient  rally  from  this  heart-failure, 
due,  I  think,  to  the  depressing  influence  of  the  chloroform.  It 
was  carefully  administered — with  a  sponge  in  a  cone — i.e.,  a 
towel  stiffened  with  a  sheet  of  paper  in  its  folds  ;  the  sponge 
was  held  in  its  place  in  the  apex  by  transfixing  with  long  pins 
to  prevent  it  falling  down  on  the  patient's  face.  The  chloro- 
form and  ether  were  of  reliable  manufacture.  It  afterward 
developed  that  at  this  time  the  liver  was  involved  in  secondary 
cancerous  inflammation,  to  which  the  patient  succumbed  a  few 
weeks  after  recovery  from  the  operation. 

"A  more  recent  case  of  death  from  a  mixture  of  etJiefr  and 
chloroform  is  reported  in  the  Philadelphia  Medical  Times, 
March  15,  1879,  by  I.  A.  Cleary,  Assistant  Surgeon  U.  S.  A. 
Private  H.  D.  B.,  Co.  19,  U.  S.  Infantry,  aged  33,  large, 
robust ;  addicted  to  liquor.  Injury  of  middle  finger,  right 
hand,  resulting  in  gangrene ;  decided  to  amputate.  A  mixture 
of  equal  parts  of  ether  and  chloroform  {weight  or  measure  not 
stated).  Two  ounces  of  whiskey  were  given  ten  minutes  prior 
to  inhalation.  The  anaesthetic  was  administered  on  a  piece  of 
lint  covered  with  a  small  towel  held  square.  He  personally  ad- 
ministered the  mixture,  while  the  steward  observed  the  pulse ; 
air  was  freely  admitted ;  he  inhaled  freely.  About  two  drachms 
were  first  poured  on  the  cloth,  but  with  no  apparent  eflFect  Qie^ 
evidently^  receiving  nothing  hut  ether).  Shortly  after  about  the 
same  quantity  was  poured  on  ;  he  observed  that  '  he  did  not 
feel  it. '  After  a  time  about  the  same  quantity  was  again  poured 
on.  A  further  quantity  was  poured  on  the  cloth  (say,  in  all, 
^viij),  when  he  began  to  laugh,  followed  by  attempts  to  articu- 
late, and  made  strong  gesticulations  with  his  arms.  He  now 
passed  to  a  state  of  unconsciousness,  when  the  pulse  was  not 
perceived.  This  was  followed  by  relaxation  and  death.  At  once 
the  anaesthetic  was  removed ;  cold  water  dashed  in  the  face. 
He  adds,  '  Everything  I  ever  heard  of,  saw  or  read,  appropriate 
for  such  a  case,  was  done,  but  to  no  efi"ect. '  He  states  as  the 
cause  of  death  paralysis  of  the  heart  (I  think  it  was  syncope 
from  the  chloroform)." 


ADMINISTRATION  OF  NITROUS  OXIDE  AND  ETHER.        365 

How  Shall  Nitrous  Oxide  and  Ether  be  Adminis- 
tered? 

Dr.  Frederick  W.  Silk,  of  London,  an  anesthetist  of  wide 
experience,  has  invented  a  useful  apparatus  for  the  production 
of  anaesthesia  by  the  combined  method.  In  placing  his  inven- 
tion before  the  profession,  Dr.  Silk  himself  comments  on  the 
striking  similarity  in  the  principle  applied  by  him  and  that  of 
Dr.  Hewitt,  who  had  pursued  an  independent  line  of  work. 
The  only  difference  between  the  apparatus  of  Dr.  Silk  and  that 
of  Dr.  Hewitt  is,  that  the  valve  arrangement  between  the  face- 
piece  and  the  ether-chamber  in  Dr.  Hewitt's  apparatus  has  been 
transferred  by  Dr.  Silk  to  the  face-piece  itself,  where  it  is  con- 
trolled by  the  fingers  of  the  hand  holding  the  face-piece  in 
position.  Dr.  Silk  and  Dr.  Hewitt  have  both  attained  a  method 
greatly  superior  to  the  usual  one  of  an  ether  chamber  suspended 
around  the  neck,  and  connected  with  a  face-piece  by  means  of 
the  bag  inclosing  the  tube.  Dr.  Silk,  however,  considers  the 
new  method  still  defective,  because  of  the  difficulty  of  adminis- 
tering nitrous  oxide  with  a  mere  "  whiff"  of  ether,  as  in  dental 
work.  The  ether-chamber,  when  charged  so  that  the  indicator 
stands  at  0,  is  so  constructed  that  it  is  almost  impossible,  in 
warm  weather  especially,  to  prevent  a  very  distinct  and  disa- 
greeable odor  of  ether  from  pervading  the  face-piece  at  all 
times.  Dr.  Silk  saj's  that  this  apparently  trifling  objection 
becomes  a  serious  one  in  the  treatment  of  nervous  and  excitable 
patients. 

Another  difficulty  is  the  total  exclusion  of  air,  which  is  so 
important  a  feature  in  the  administration  of  nitrous  oxide. 
Complicated  mechanism— valves,  stopcocks,  chamber  and  pipe 
adjustments  render  this  total  exclusion  difficult  just  so  soon  as 
the  effects  of  wear  and  changes  of  temperature  are  manifest  in 
the  apparatus,  and  notably  toward  the  close  of  the  administra- 
tion, when  the  bag  is  becoming  empty,  and  the  inspiratory 
effort  is  greater.  Dr.  Silk  says  that  the  gas  reservoir  should  be 
brought  as  near  the  mouth  as  possible  in  all  cases,  and  espe- 
cially when  it  is  narrow,  with  various  divisions  made  by  joints, 
valves,  etc.  There  is  always  the  possibility  of  leakage,  and  gas 
is  moreover  but  feebly  mobile. 


366  ARTIFICIAL    ANESTHESIA. 

In  cases  where  nitrous  oxide  and  ether  are  administered  in 
succession  Dr.  Silk  finds  his  apparatus  often  useful  in  abolish- 
ing the  pulmonary  spasm,  and  the  struggling  which  is  manifest 
in  the  later  stages  of  narcosis  ;  but  he  expresses  disappoint- 
ment that  these  phases  have  not  been  entirely  abolished,  and 
that  in  some  instances  they  have  seemed  to  be  intensified.  This 
he  attributes  largely  to  the  greater  rapidity  with  which  nitrous 
oxide  narcosis  is  produced,  as  compared  with  that  following  • 
ether,  the  former  growing  quite  profound  before  the  latter  has 
reached  the  first  stage.  The  consequent  necessity  for  admitting 
air  at  that  period  retards  the  development  of  the  final  stages  of 
ether  narcosis,  and  prolongs  or  even  intensifies  the  stage  of 
struggling  and  excitement.  In  commenting  on  Dr.  Hewitt's 
and  his  own  apparatus,  Dr,  Silk  saj^s  :  "I  am  bound  to  con- 
fess, however,  that  it  is  a  very  distinct  improvement  on  old 
methods,  and  that  I  still  continue  its  use." — Medical  Register^ 
October,  298. 

Mixtures  of  Nitrous  Oxide,  Etliers,  CWoroforni  aud 
Alcohol  for  Inhalation. 

In  our  numerous  experiments  with  the  various  angesthetic 
agents  we  have  always  found  it  difl&cult  to  make  any  true  chem- 
ical combination.  Most  of  the  vapors  diifer  very  much  in 
density,  and  are  given  off  at  different  temperatures,  the  vapor 
of  chloroform  being  four  times  heavier  than  air  ;  and  unless 
some  means  are  employed  to  keep  them  in  motion  the  denser 
vapor  will  gravitate  to  the  bottom.  Such  is  also  the  case  with 
the  liquid  anaesthetics.  They  will,  when  shaken  up,  look,  for 
the  time,  a  perfect  mixture  ;  but  if  allowed  to  stand,  the  heavier 
liquid,  like  chloroform,  will  sink  to  the  bottom,  and  if  the  bot- 
tle is  not  well  shaken  each  time  when  used  the  patient  is  apt, 
during  the  conclusion  of  a  tedious  operation,  to  receive  the 
chloroform  almost  pure.  The  combination  of  nitrous  oxide 
with  ether  had  been  carried  out  in  England  for  many  years,  and 
we  have  given  a  description  of  Clover's  apparatus,  with  his 
careful  directions  for  use.  Then  we  have  the  useful  inhaling 
apparatus  of  Dr.  Buxton,  of  London,  with  a  reference  to  that 
of  Drs.  Silk  and  Hewitt ;  also  that  of  Drs.  Codman  and  Shurt- 


MIXTURES    FOR    INHALATION.  367 

leff,  of  Boston.  Another  convenient  attachment  has  been 
arranged  by  Dr.  A.  M.  Long,  by  which  the  nitrous  oxide  gas  is 
condensed  into  a  liquid,  and  then  mixed  with  ether,  drop  by 
drop,  in  a  combining  chamber.  This  apparatus  has  been  em- 
ployed, to  a  limited  extent,  at  the  Philadelphia  Dental  College, 
combining  from  twenty  to  thirty  drops  of  ether  to  five  gallons 
of  the  gas.  It  is  well  known  that  both  nitrous  oxide  gas  and  ether 
are  stimulants,  and  this  combination  should  never  be  given  to 
persons  of  full  habit  or  flushed  face,  for  fear  of  overaction  of 
the  vessels  of  the  brain,  producing  convulsion  or  apoplexy. 
Mixtures  of  chloroform  and  nitrous  oxide,  or  chloroform,  alco- 
hol and  nitrous  oxide,  in  the  proportions  of  from  five  to  six  drops 
to  five  gallons  of  the  gas,  have  been  employed  ;  but  the  fear  is 
that  unscrupulous  persons  would  not  limit  themselves  to  this 
quantity,  but  would  use  a  larger  proportion,  running  the  risk  of 
destroying  their  patient. 

We  have  already  given  our  opinion  of  preparatory  anaes- 
thetic combinations  of  various  agents  to  disguise  the  taste  and 
smell  of  the  anaesthetic,  under  bromide  of  ethyl,  and  would 
advise  all  persons  administering  anaesthetics  to  be  sure  of  the 
agent  they  employ,  so  as  to  be  able  to  counteract  any  dangerous 
element. 

A  mixture  of  nitrous  oxide  and  ether  vapor  would  explode 
on  contact  with  flame  or  even  a  spark.  It  would  not  be  spon- 
taneously explosive,  and  would  not  be  more  dangerous  than  a 
mixture  of  ether  vapor  and  air. 


368 


ARTIFICIAL    ANESTHESIA, 


Junker's  Iiilialer. 

Plate  50, 


There  should  have  been  inserted  at  page  246  this  plate  of 
Junker's  Inhaler  for  Chloroform,  a  full  description  of  which 
will  be  found  on  that  page. 


SOUCHON  S    IMPROVED    AN^STHETIZER. 


369 


Soiiclion's  Improved  Anaestlietizer. 

[The  cuts  in  this  article  were  not  received  in  time  to  be  in- 
serted in  the  paper  on  page  178.  "We  therefore  repeat  a  portion 
of  the  description  which  had  to  be  omitted  at  that  time.] 


Plate  51. 


Fr^n 


"Description  of  Apparatus.— The  present  improved  appa- 
ratus is  considered  perfect  in  all  particulars.    It  is  composed  of 


370  ARTIFICIAL    ANAESTHESIA. 

a  glass  cylindrical  receptacle,  with  a  frame  supporting  a  ring,  A, 
for  the  thumb  and  a  rubber  bulb,  B,  so  that  it  can  be  worked 
with  one  hand.  From  the  bulb  originates  a  rubber  tube,  C, 
wrapped  with  coiled  wire  to  prevent  it  from  bending ;  it  ends 
in  the  inlet-tube,  J) ;  just  at  the  point  of  junction,  at  E,  is  a 
ball-valve  which  prevents  the  liquid  from  entering  the  bulb 
when  the  pressure  upon  the  latter  is  released.  The  inlet-tube 
extends  through  the  liquid  anaesthetic  to  the  very  bottom  ;  its 
lower  end  is  bevelled  to  prevent  the  orifice  from  being  stopped 
by  coming  in  contact  with  the  bottom  of  the  receptacle. 

"This  inlet-tube  slides  up  and  down  through  another  shorter 
tube,  D\  so  that  it  can  be  drawn  well  up  above  the  level  of  the 
liquid  anaesthetic,  thereby  diminishing  the  strength  of  the 
vapors  injected  through  the  outlet-tube  into  the  pharynx.  This 
feature  makes  the  apparatus  thus  set  an  ansesthetizer  of  the 
first  model. 

' '  The  receptacle  is  closed  by  a  metallic  lid  that  screws  around 
its  neck  ;  a  washer  makes  it  air-tight. 

"From  this  lid  springs  the  metallic  portion  of  the  outlet-tube, 
F  ;  it  originates  directly  from  the  under  surface  of  the  lid  ;  it  is 
i  inch  in  diameter  inside  and  1  i  inches  in  height ;  after  a  very 
sharp  curve  of  90°,  it  terminates  by  an  orifice  of  not  loss  than 
3^  inch." 


PART    FIFTH. 


CHAPTER    XII I. 

Local  Anaesthesia  and  Aneesthetics, 

Electrical  Osmosis  aocl  Cataplioresis. 

Local  anaesthesia  has  for  its  object  to  abolish  the  sensibility 
of  the  skin  and  other  parts  of  the  body.  This  is  accomplished 
by  certain  local  anaesthetics  or  substances  which  diminish  the 
sensibility  of  the  part  by  their  contracting  influence  upon  the 
peripheral  or  surface  nerves  or  filaments  of  the  deeper-seated 
nerves.  The  use  of  cold  was  one  of  the  earliest  and  most  effi- 
cient means  of  producing  local  anaesthesia,  either  in  the  form 
of  snow  or  ice,  with  or  without  the  chloride  of  sodium,  or 
common  salt,  which  was  mixed  with  the  broken  ice  and  applied 
in  a  bag  of  linen,  or  now  in  a  better  form  by  the  use  of  a  rubber 
bag,  which  is  arranged  both  for  the  convenience  and  comfort 
of  the  patient.  The  injection  of  ice-water  is  also  used  as  a 
local  anaesthetic.  Then  followed  soon  after  their  discovery, 
and  to  obviate  the  dangers  of  a  general  anesthesia,  the  use 
of  chloroform,  ether,  bromide  of  ethj^l,  rhigolene,  carbon  bi- 
sulphide, absolute  alcohol,  carbonic  and  carboHc  acids,  hydro- 
chlorate  of  ammonia,  also  the  bromide  and  sulphate  of  am- 
monia. The  iron  salts,  particularly  the  sesquioxide,  have  an 
anaesthetic  action  without  producing  coagulation  at  the  point  of 
introduction.  Acetate  of  lead  is  also  an  anaesthetic,  and  among 
organic  substances,  hydroquinine,  resorcin,  antipyrin,  substances 
belonging  to  the  digitalis  group,  and  serpent  venom,  in  small 
doses.  Essential  oils,  such  as  oil  of  turpentine,  hydrate  of  ter- 
ebene,  eucalyptol,  oil  of  chamomile  flowers,  and  a  number  of 
others,  have  a  remarkable  effect,  according  to  Dr.  Liebreich, 
who  states  that  these  substances  act  by  destroying  the  nerve 
ends  and  by  irritating  the  neighboring  parts,  causing  what  has 
been  called  "'painful  anaesthesia."     Many  of  these  agents  act 


372  ARTIFICIAL    ANESTHESIA. 

by  entering  the  circulation,  and  others  by  their  direct  effect 
upon  the  tissues.  With  regard  to  the  cornea,  there  are  two 
kinds  of  anassthesia  by  subcutaneous  injection  of  the  dorsal  re- 
gion in  rabbits  and  guinea  pigs  ;  for  the  eye^  by  allowing  a  few 
drops  of  the  substance  in  solution  to  fall  on  the  cornea.  In 
preparing  solutions,  even  of  distilled  waters,  we  must  remember 
that  the  water  acts  as  a  caustic,  and  must  be  sterilized.  The 
most  important  and  valuable  of  all  these  local  anaesthetics  is 
cocaine,  which  causes  no  pain.  It  is,  however,  followed  by 
contraction  of  the  vessels. 

Electricity  as  a  Local  Ansestlietic  Alone  or  witli 

Cocaine. 

The  pain  felt  during  the  extraction  of  a  tooth  is  lessened  by 
the  emploj^ment  of  rapid  respiration  (Bonwell's  method),  vio- 
lent muscular  effort,  or  vibration.  A  still  more  powerful  ad- 
junct is  electricity  applied  along  the  course  of  the  nerves.  The 
Faradaic,  or  interrupted  galvanic  current,  was  at  one  time  em- 
ployed in  this  city  to  produce  a  local  anaesthesia.  This  employ- 
ment of  electricity  has  been  revived  by  Dr.  I.  Corning,  of  New 
York,  by  first  perforating  the  skin  with  needles  with  the  instru- 
ment of  "Baunschiedt,"  and  then  applying  over  the  surface  a 
sponge  electrode  saturated  with  a  two  per  cent,  solution  of  hy- 
drochlorate  of  cocaine.  This  should  be  kept  connected  with  the 
battery  from  three  to  four  minutes,  and  be  of  sufficient  intensity 
to  cause  a  slight  sensation  of  heat.  It  has  been  found  safer, 
and  that  the  method  can  be  made  more  efficient,  if  the  surface 
be  blanched  by  the  pressure  of  Esmarch's  rubber  bandage,  as 
by  this  means  strong  solutions  of  cocaine  can  be  employed  with 
more  safety. 

Electrical  Osmosis  for  tlie  Treatment  of  Living- 
Dentine.* 

Electrical  osmosis,  electrical  diffusion,  anodal  diffusion,  and 
cataphoresis  are  terms  used  by  different  authorities  to  express 
nearly  the  same  phenomena. 

*  Eead  before  the  New  York  Institute  of  Stomatology,  November 
26,  1895,  by  Henry  W.  Gillett,  D.  M.D.  Reprint,  Newport,  February, 
1896  ;  also  International  Dental  Journal,  February,  1896, 


OSMOSIS    FOR    TREATMENT    OF    LIVING    DENTINE.       373 

The  first  three  terms  will  be  recognized  as  entirely  synony- 
mous, and  need  no  defining  to  make  them  intelligible. 

Electrical  osmosis,  the  one  chosen  for  my  title,  is  probably 
the  one  having  the  widest  acceptation  among  electricians. 

Cataphoresis  is  a  medical  term  which  has  come  into  use 
among  electrotherapeutists,  and  is  recognized  by  few  electrical 
experts  outside  of  those  interested  in  medicine. 

The  definition  of  the  term  given  by  Dr.  "William  J.  Morton* 
seems  to  cover  the  ground  fully.     It  is  this  : 

' '  The  movements  of  fluids,  together  with  the  substances  they 
hold  in  solution,  from  the  positive  pole  of  electrodes  conveying 
a  continuous  current  in  tissue  towards  the  negative  pole." 

"When  we  consider  this  definition  in  connection  with  the 
human  tooth,  which  generations  of  our  profession  have  been 
striving  to  penetrate  with  some  drug  which  should  modify  its 
sensitiveness,  or  with  applications  which  should  modify  morbid 
conditions  of  the  tooth-pulp,  it  becomes  at  once  important,  and, 
indeed,  imperative  that  we  make  use  of  this  principle,  if  we  find 
it  possible  to  do  so.  It  is  not  necessary  for  me  to  mention 
before  this  audience  the  many  advantages  to  accrue,  for  both 
patient  and  operator,  from  any  feasible  and  harmless  method  of 
subduing  the  sensitiveness  of  the  dentine  of  the  human  tooth. 

"  It  is  equally  unnecessary  for  me  to  enumerate  the  many  dif- 
ferent means  that  have  been  tried  to  attain  this  end.  It  has 
not  always  happened  that  the  means  which  have  been  tried  and 
found  helpful  have  proved  harmless.  The  ill  results  from  the 
use  of  arsenic  and  the  strong  mineral  acids  are  examples  of  this 
fact.  I  have  been  amazed,  within  a  year  or  two,  to  find  a  set 
of  these  so-called  obtundents  indorsed  by  members  of  our  pro- 
fession of  recognized  standing,  which  are  of  a  most  pernicious 
character.  Upon  applying  to  them  simple  tests  within  the 
reach  of  every  intelligent  operator,  they  reveal  the  fact  that 
their  efficiency  is  due  to  the  most  corrosive  mineral  acids. ' ' 

Of  course,  every  progressive  operator  has  certain  applications 
which  he  uses  with  success  in  some  percentage  of  cases,  but  I 

*  Cataphoresis  and  solution  of  H2O2  for  bleaching  teeth,  etc.,  Den- 
tal Cosmos,  June,  1895.  Note  also  the  terms  electric  diffusion  and 
electric  medicamental  diffusion,  proposed  by  Dr.  W.  J.  Morton. 


374  ARTIFICIAL    ANAESTHESIA. 

think  it  is  the  universal  experience  to  find  that,  in  many  of  the 
cases  where  we  need  help  most,  none  of  these  applications  are 
of  much  assistance. 

"For  several  years  I  have  been  taking  a  keen  interest  in  a 
method  of  applying  drugs  to  sensitive  dentine,  which  seemed  to 
promise  a  more  universal  usefulness  than  anything  which  we 
have  before  had  at  our  command."* 

Dr.  Gillett  sums  up  the  results  of  his  experiments  as  fol- 
lows :  Ten  per  cent,  aqueous  solution  of  cocaine  applied  on  the 
positive  electrode  with  a  weak  electric  current  for  a  few  minutes 
will  anaesthetize  the  skin.     (Experiment  No.  1.) 

A  similar  cocaine  solution  applied  for  the  same  time  without 
the  current  has  no  angesthetic  effect.     (Experiment  No.  2. ) 

The  same  electric  current  without  the  cocaine  has  no  anaes- 
thetic effect.     (Experiment  No.  3.) 

Cocaine  solutions  of  from  fifteen  to  twenty-five  per  cent,  ap- 
plied in  sensitive  cavities  for  ten  or  twenty  minutes  do  not 
modify  their  sensitiveness.     (Experiments  Nos.  4,  5,  6. ) 

The  electric  current  alone  applied  to  sensitive  dentine, 
sodium-chloride  solutions  of  varying  strengths  being  added  to 
insure  good  electrical  connections,  does  not  perceptibly  modify 
the  sensitiveness.     (Experiments  Nos.  8,  9,  11.) 

Cocaine  solutions  and  the  electric  current  applied  to  sensitive 
dentine,  together,  do  completely  anaesthetize  it ;  consequently 
the  cocaine  is  the  active  agent.     (Experiments  Nos.  7,  10,  12.) 

This  treatment  renders  it  possible  to  do  for  these  nervous 
and  hypersensitive  organizations  desirable  operations,  which, 
without  some  such  means,  are  utterly  impossible.  It  also  en- 
ables the  operator  to  perform  much  more  satisfactory  opera- 
tions for  sensitive  children  from  twelve  to  sixteen  years  of  age, 
and  to  do  these  operations  (which  would  otherwise  be  entirely 
too  formidable  to  contemplate)  with  no  objection  from  the  little 
patient  and  with  no  danger  of  exhaustion  afterwards. 

The  effect  of  the  cocaine  in  these  applications  does  not  seem 
to  reach  deeply  into  the  dentine  in  most  cases.     By  prolonging 

*  Dr.  Gillett  gives  a  full  resume  of  wliat  had  been  done  prior  to  his 
own  experiments,  which  we  have  not  space  to  give,  but  would  recom- 
mend our  readers  to  the  original  paper. 


OSMOSIS    FOR    TREATMENT    OF    LIVING    DENTINE.       375 

the  application,  however,  the  pulp  itself  may,  in  favorable 
cases,  be  anaesthetized,  even  through  a  layer  of  dentine. 

It  is  quite  often  the  case  that  a  ten-  or  twelve-minute  appli- 
cation will  anaesthetize  the  dentine  deeply  enough  to  allow  the 
greater  portion  or  all  of  the  cutting  to  be  done  painlessly,  but 
for  deep  grooves  it  may  be  necessary  to  repeat  the  application. 
In  cases  where  there  is  much  sensitiveness,  and  consequently 
much  time  will  be  required  to  prepare  the  cavity  at  all,  I  find 
the  time  required  for  applying  the  cocaine  is  fully  made  up  by  the 
increased  speed  possible  after  the  sensitiveness  is  under  control. 

"  As  to  the  time  the  cocaine  effect  persists,  I  find  it  difficult 
to  get  accurate  knowledge.  I  am  not  always  able  to  be  certain 
whether  renewed  sensitiveness  is  due  to  penetration  through 
the  anaesthetized  layer  or  to  returning  sensation.  I  had  ex- 
pected that  the  effect  would  be  more  lasting  than  cocaine  effects 
in  tissues,  where  the  circulation  is  more  rapid.  I  have,  how- 
ever, seen-  one  or  two  cases  where  there  had  been  a  profound 
effect  produced  and  where  there  was  a  return  of  the  sensitive- 
ness in  fifteen  or  twenty  minutes. 

"  As  to  the  effect  upon  the  pulp  or  the  tooth,  I  have  examined 
some  of  the  teeth  where  the  first  applications  were  made,  and 
I  am  unable  to  find  any  trace  whatever  of  a  permanent  change 
in  their  condition. 

"  Some  of  my  first  work  with  cocaine  and  electrical  osmosis 
was  done  in  my  own  mouth.  Stronger  currents  were  used  than 
I  dare  to  apply  in  the  mouths  of  my  patients,  and  deep  anaes- 
thetic effects  were  obtained.  No  ill  results  have  followed,  and 
the  tooth  is  normal  in  its  sensitiveness  after  nearly  a  year's 
test.  As  to  the  applicability  of  the  method,  I  find  that  it  is 
almost  universal.  The  exceptions  are  in  the  cases  of  the  com- 
paratively rare  subjects  who  are  not  readily  affected  by  cocaine, 
and  the  occasional  case  where  the  difficulties  of  insulating  the 
tooth  or  cavity  are  too  great. 

"This  latter  class  of  cases  will  be  much  smaller  in  the  hands 
of  the  expert  operator,  and  this  added  necessity  for  the  rubber 
dam  will  stimulate  the  operator's  ingenuity  in  applying  it  in 
difficult  cases.  I  very  seldom  find  a  case  where  I  am  unable  to 
use  the  method  with  success,  if  I  desire  to  do  so. 


376  ARTIFICIAL    ANAESTHESIA. 

"  In  my  use  of  electrical  osmosis  I  have  found  a  single  patient 
who  is  so  sensitive  to  the  current  as  to  be  only  able  to  take  a 
seven-volt  current  as  a  maximum.  For  her  I  readily  anaesthet- 
ized a  bicuspid  so  as  to  remove  a  portion  of  the  pulp,  but  a 
large  molar  cavity  required  a  long  application,  and  was  only  a 
partial  success. 

"  As  to  deep  anaesthetic  effects  about  the  roots  of  teeth,  I  have 
not  met  with  success  in  the  limited  trials  I  have  made.  I  have 
received  numerous  queries  as  to  the  use  of  the  inethod  for  ex^- 
tracting,  but  I  see  no  probability  of  its  replacing  the  present 
methods  for  that  purpose.  I  have  made  one  or  two  attempts 
to  reach  the  nerve  branches  entering  the  tooth  by  applying  the 
electrodes  on  opposite  sides  of  the  gums.  The  results  were  not 
encouraging,  and  in  the  case  where  my  most  determined  efforts 
were  made  I  produced  a  decidedly  objectionable  result  in  the 
breaking  down  of  the  gum  tissue  under  the  positive  electrode. 
I  have,  however,  obtained  satisfactory  results  from  cocaine 
cataphoresis  on  the  sensitive  gum  about  roots  undergoing  prep- 
aration from  crowning. 

"It  would  seem  to  me  feasible  to  treat  by  electrical  osmosis 
that  very  troublesome  condition  resulting  from  undue  wear  or 
erosion  of  the  grinding  surfaces  of  molar  teeth,  where  the  sen- 
sitiveness is  almost  a  menace  to  health,  by  reason  of  its  pre- 
venting proper  mastication,  and  where  it  defies  the  action  of 
the  most  violent  caustics. 

' '  For  doing  this  work  I  have  had  made  the  instrument  you 
see  before  you,  technically  an  adapter  or  fractional  volt  selecter, 
the  working  of  which  I  will  explain. 

' '  A  milliampere  metre  is  also  almost  essential.  This  selecter 
is  intended  for  use  with  the  Edison  one  hundred  and  ten  volt 
continuous  current.  I  have  the  Electro -Therapeutic  Company  at 
work  devising  a  battery  apparatus  for  use  instead  of  the  Edison 
current.  I  have  not  used  batteries  because  I  did  not  want  to 
have  the  care  of  them,  but  when  the  incandescent  current  is  not 
accessible,  battery  systems  with  a  capacity  of  thirty  or  more  volts 
may  be  successfully  used  with  suitable  modifying  apparatus. 

"  First,  let  me  enumerate  the  precautions  necessary  in  using 
the  one  hundred  and  ten  volt  current." 


OSMOSIS    FOR   TREATMENT    OF    LIVING    DENTINE.       377 

Have  the  selecter  connected  according  to  the  instructions 
provided  with  it. 

An  absolute  safeguard,  but  one  not  necessary  if  connections 
are  properly  made,  is  to  insulate  the  chair  by  placing  linoleum 
or  rubber  under  its  feet,  and  also  to  see  that  gas  pipes,  water 
pipes,  and  any  other  wires  are  out  of  the  reach  or  protected 
from  contact. 

"  I  always  apply  the  rubber  dam,  as  it  is  difficult,  and  often 
impossible,  to  prevent  leakage  of  current  through  other  tissues 
if  this  is  not  done. 

"Any  metal  fillings  which  will  be  in  contact  with  the  wet 
cotton  in  the  cavity  or  with  the  electrode  must  be  covered.  The 
current  from  a  metallic  surface  into  dentine  is  irritating  and 
painful.  I  find  Gilbert's  temporary  stopping  a  very  useful  mate- 
rial for  this  purpose.  Wax  will  also  do.  In  caises  where  I  am 
working  on  an  approximal  cavity  in  one  tooth,  and  a  filling  in 
the  next  tooth  is  too  close  to  allow  of  its  satisfactory  insulation, 
I  apply  the  rubber  at  first  onl}'^  over  the  tooth  to  be  worked 
upon,  thus  insulating  it  completely ;  or,  if  the  rubber  is  already 
in  place,  a  second  rubber  may  be  applied  over  the  tooth  to  be 
worked  upon.  The  positive  electrode  should  be  of  platinum, 
as  most  other  metals  are  affected  by  the  current  and  are  liable 
to  stain  the  tooth. 

"  These  conditions  being  provided,  see  that  j^our  current  is 
turned  on.  I  always  test  this  by  touching  the  metal  parts  of  the 
electrodes  together,  and  watch  the  milliampere  meter  to  ob- 
serve the  result. ' ' 

"This  selecter  is  so  arranged  that  when  the  needle  is  at  zero, 
and  contact  of  electrodes  is  made  as  described,  about  one  mill 
will  be  recorded.  Getting  this  result  insures  the  operator  that 
all  connections  have  been  made  and  that  the  apparatus  is  ready. 
If,  however,  a  larger  quantity  of  current  is  indicated  by  the 
milliampere  meter,  it  shows  that  the  rheostat  contact  is  not  at 
the  right  place.  This  same  proceeding  would  also  serve  to  de- 
tect any  break-down  in  the  rheostat  if  it  had  occurred.  Twenty 
seconds  serve  to  assure  the  operator  on  these  points  if  his  appa- 
ratus is  conveniently  placed.  I  then  wet  the  negative  sponge 
electrode  with  water  or  dilute  salt  solution.     I  place  in  the 

25 


378  ARTIFICIAL    ANESTHESIA. 

cavity  a  pellet  of  absorbent  cotton  saturated  with  a  twenty  to 
thirty  per  cent,  cocaine  solution.  I  prefer  not  to  have  this 
cotton  extend  outside  of  the  cavity,  and  to  keep  the  solution 
confined  to  the  cavity  as  much  as  possible.  This  concentrates 
the  current  in  the  part  I  desire  to  affect. 

"The  negative  wet  sponge  electrode  I  usually  allow  the  patient 
to  hold  most  of  the  time.  It  is  preferable  to  be  applied  about 
the  face  or  neck,  as  near  the  tooth  as  is  convenient.  Having 
placed  this  and  allowed  the  patient  to  take  it,  I  apply  the  posi- 
tive electrode  to  the  cotton  in  the  cavity  and  begin  slowly  to 
increase  the  current  by  turning  the  large  fibre  knob  of  the 
rheostat  head  in  the  direction  indicated  by  the  needle  which 
records  voltage.  The  first  consciousness  of  the  current  some- 
times comes  to  the  patient  as  the  typical  little  *  kick '  or 
'  kink  '  of  the  -galvanic  current,  but  it  is  a  very  small  one  with 
this  selecter.  More  often  the  patient  is  only  conscious  of  an 
indefinite,  gradually  increasing  pressure,  and  if  the  current  is 
pushed  too  rapidly  this  may  increase  to  pain.  It  is  therefore 
necessary  to  watch  the  patient  carefully,  and  to  pause  in  the 
turning-on  process  as  soon  as  the  change  in  the  eye  of  the  pa- 
tient indicates  that  he  is  beginning  to  feel  the  current  to  an 
uncomfortable  degree. 

"After  the  first  experience,  if  cautiously  managed,  a  patient 
will  usually  give  the  operator  all  necessary  indications  for  his 
guidance,  and  allow  him  to  keep  the  current  up  to  a  point  just 
short  of  pain. 

"After  one  experience  with  it  the  sensation  is  readily  borne, 
even  by  sensitive  children  of  twelve  or  fourteen.  In  fact,  they 
are  often  the  most  enthusiastic  about  its  use. 

"As  the  operator  pauses  at  the  point  where  the  patient  indi- 
cates that  he  is  getting  enough,  or  even  turns  back  a  little  if 
there  is  too  much  current,  it  is  well  to  assure  the  patient  that 
any  disagreeable  sensation  will  subside  promptly.  It  usually 
does  this  in  from  one-half  minute  to  two  minutes,  and  then  the 
voltage  may  be  increased  slowly  and  gradually,  with  pauses 
long  enough  for  any  disagreable  sensation  to  disappear. 

"  Subjects  differ  very  much  in  the  amount  of  current  they  will 
-bear  without  discomfort.     It  is  usually  found,  however,  that  by 


OSMOSIS    FOR    TREATMENT    OF    LIVING    DENTINE.       379 

very  gradual  increase,  and  by  taking  more  time  to  reach  the 
maximum  in  these  sensitive  cases,  a  sufficient  amount  may  be 
applied  to  any  case  to  attain  the  result  of  anaesthetizing  the 
dentine. 

"It  is  my  customary  habit,  as  soon  as  I  have  opened  into  a 
sensitive  cavity,  to  make  an  application  lasting  from  eight  to 
twelve  minutes.  If  I  have  reason  to  expect  difficulty  with  the 
case  I  make  the  application  longer.  If  the  first  application  is  not 
sufficient  for  all  I  wish  to  do  I  repeat  it  later. 

"  I  have  some  ten  or  twelve  cases  on  record  where  twenty  to 
thirty  minutes  have  been  needed  to  get  sufficient  effect.  These 
were  all  cases  where  both  patient  and  operator  felt  compensated 
for  the  time  spent.  Most  of  them  were  either  extremely  sen- 
sitive teeth  or  subjects  who  could  bear  but  little  current,  and 
several  of  these  cases  would  have  been  all  but  impossible  with- 
out the  aid  of  this  method. 

"On  the  other  hand,  I  have  numerous  cases  where  ten  or 
even  eight  minutes  have  been  ample  time  for  successful  results. 
."  Having  reached  a  voltage  likely  to  be  sufficient,  I  allow  it 
to  stand  at  that  point  till  the  end  of  the  application. 

"Fifteen  to  twenty  volts  will  usually  be  attained  in  seven  or 
eight  minutes.  In  many  cases,  with  small  cavities  and  little 
sensitiveness  to  the  current,  twenty-five  or  thirty  volts  may  be 
marked  in  the  same  time. 

"The  higher  voltage  works  more  rapidly. 

"At  the  end  of  the  application  I  usually  break  connection  at 
the  negative  electrode,  as  there  is  less  often  any  shock  in  so 
doing.  If  the  subject  is  very  sensitive  to  the  current,  I  turn 
the  voltage  down  low  before  breaking  connection. 

"Having  concluded  the  application,  I  turn  off  the  current  in 
the  selector  by  means  of  the  switch.  This  lever  may  also  be 
used  for  concluding  the  application  of  current  if  you  find  no 
objectionable  shock  resulting. 

"Then  I  test  the  cavity,  and  finding  it  all  right  proceed  as 
usual,  bearing  in  mind  that  the  effect  may  not  have  gone  as 
deeply  as  I  wish  to  go  with  my  instruments,  so  it  is  still  neces- 
sary to  watch  for  signs  of  returning  sensitiveness. 

"The  expert  electrical  knowledge  required  for  this  process  is 


380  ARTIFICIAL    ANESTHESIA. 

not  such  as  to  be  a  formidable  obstacle  to  any  skilful  prac- 
titioner. The  instructions  provided  will  serve  to  arm  him  with 
sufficient  knowledge  for  his  first  cases,  and  the  other  needed 
knowledge  will  come  to  him  quickly  as  he  goes  on  with  his 
work. 

"In  connecting  this  selecter,  it  is  only  necessary  to  screw  the 
plug  provided  into  a  lamp  socket,  and  place  the  cords  in  the 
binding  posts.  Carry  the  wire  from  the  positive  binding  post 
to  the  binding  post  of  the  milliampere  metre,  which  is  marked 
+  (positive).  Connect  the  cord  attached  to  the  positive  plati- 
num electrode  to  the  other  post  of  the  milliampere  metre,  then 
lead  the  cord  of  the  negative  electrode  from  the  unused  post  of 
the  selecter. 

"The  electrodes  may  be  readily  detected  by  passing  a  current 
through  a  small  piece  of  wet  litmus  paper.  The  positive  pole 
will  be  found  to  redden  the  litmus,  while  the  negative  turns  it 
blue." 

The  author  reports  a  number  of  interesting  and  successful 
cases. 

After  a  year's  employment  of  electrical  osmosis  or  cataphore- 
sis  by  the  method  proposed  and  kindly  explained  in  the  pres- 
ence of  several  well-known  physicians  and  dental  doctors  by  its 
author,  Henry  W.  Grillett,  D.M.D.,  it  has  been  found  by  a 
good  number  of  practitioners  to  be  an  efficient  aid,  particularly 
applicable  to  the  cases  of  most  extremely  sensitive  dentine. 

Guaiacol-Cocaine  Cataplioresis. 

In  a  recent  address  before  a  New  York  dental  society,  Dr. 
James  Morton  described  a  method  of  producing  local  anaesthe- 
sia"^ more  rapidly  and  more  profoundly  than  by  any  means  before 
known  to  him.  This  was  by  the  use  of  guaiacol  as  a  solvent  for 
hydrochlorate  of  cocaine,  and  caused  to  penetrate  tissue  by  the 
aid  of  the  electric  current,  upon  the  principle  of  electro-physics 
cataphoresis  which  we  have  before  referred  to. 

The  writer  states  that  electro-guaiacol  cocaine  anassthesia  re- 

*  The  Dental  Cosmos,  January,  1896,  No.  1,  page  48. 


CONCLUSIONS.  381 

quires  two-thirds  less  time  and  two-thirds  less  current  than 
aqueous  solution  of  cocaine  used  by  the  cataphoric  method. 
The  formula  for  the  mixture  is  : 

^    Guaiacol, 5j. 

Cocaine  hydrochlorate, gr.    M. 

These  quantities  constitute  a  strong  solution,  containing  from 
eight  per  cent,  of  cocaine  to  thirty-two  per  cent.,  and  can,  if 
desired  (but  we  trust  will  not),  be  used  without  a  great  amount 
of  care  on  the  part  of  the  operator. 

Having  already  experimented  with  this  new  preparation  on 
the  skin  and  mucous  membrane,  he  then  employed  it  in  produc- 
ing anaesthesia  of  sensitive  dentine,  and  he  states  with  perfect 
success  in  cases  reported. 

He  employed  a  new  "  fractional  volt  selecter  "  of  the  Electro- 
Therapeutic  Co.,  which  he  states  worked  perfectlj^,  controlling 
device  of  the  current  from  the  street  mains.  x\lso  a  new  cata- 
phoric electrode,  b}^  which  the  application  is  made  to  both  sides 
of  the  gum. 

Conclusions.* 

"1.  Electric  medicamental  diffusion  (' cataphoresis ')  is  not 
only  a  possible  but  a  practical  procedure ;  since, 

"2.  Sensitive  dentine  may,  with  the  greatest  ease,  be  so 
thoroughly  anaesthetized  that  operations  upon  it  and  in  it 
cause  no  pain. 

'*  3.  The  dental  pulp,  even  though  not  fully  exposed,  may  be 
anaesthetized  so  that  instruments  may  enter  the  pulp  cavity 
without  causing  pain. 

"4.  By  emploj^ing  a  properly  constructed  electrode,  soft  tis- 
sues like  the  gums  may  be  completely  anaesthetized. 

"5.  Soft  tissues,  like  large  areas  (three  inches  by  one  and 
one-half  inches  by  one-half  inch  deep)  of  the  derma  and  sub- 
jacent tissues,  may  be  completely  anaesthetized  for  surgery." 

This  can  be  done  without  any  current,  by  the  Schleich  method. 

*  Dental  Cosmos,  January,  1896. 


382  ARTIFICIAL    ANAESTHESIA. 

"  6.  Gruaiacol  alone  and  other  similar  substances  and  deriva- 
tives in  themselves  non-conductors  of  electricity,  by  the  addition 
of  a  very  minute  quantity  of  some  innocent  substance  of  an  elec- 
trolytic nature,  may  be  caused  to  penetrate  tissue  by  the  aid  of 
electricity,  and  thus  exhibit  anaesthetic  effects  unobtainable 
without  the  aid  of  the  added  electrolyte. 

"  7.  Guaiacol  restrains  the  action  of  cocaine  to  local  territory  ; 
increases  the  rate  of  its  cataphoric  penetration  through  the  epi- 
dermis and  other  tissues ;  shows  the  rate  of  its  absorption  into 
the  system ;  prevents  consequent  toxic  effects ;  and  adds  its 
own  anaesthetic  qualities  to  those  of  cocaine. ' ' 

After  considerable  use  of  guaiacol  (see  page  on  guaiacol)  by  the 
dental  profession,  it  was  found  at  times,  either  from  impurities 
or  its  own  nature  being  a  creasote,  a  form  of  carbolic  acid,  to 
act  as  an  irritant  and  caustic,  so  that  it  is  no  longer  employed 
alone,  but  with  fifteen  per  cent,  of  anhydrous  hydrochlorate  of 
cocaine,  and  termed  guaiacocaine."^ 

Dr.  E.  C.  Kirk,  of  Philadelphia,  and  W.  J.  Younger,  of 
San  Francisco,  report  excellent  results  from  the  use  of  guaia- 
cocaine. 

I)r.  Kirk  says  that  complete  anaesthesia  was  produced  in  six 
and  a  half  minutes,  using  a  current  varying  from  one-tenth  to 
four  and  a  half  milliamperes. 

At  the  Post-Grraduate  School  and  Hospital,  New  York,  Dr. 
F.  N,  Wilson  removed  a  large  pigmented  naevus  from  a  patient. 
The  naevus  was  three  inches  long  by  one  and  a  half  inches 
broad,  and  complete  anaesthesia  was  obtained  in  five  minutes, 
using  the  electric  current  as  an  adjunct.  No  pain  was  felt 
during  the  operation,  nor  whilst  ten  deep  stitches  were  being 
inserted  to  close  the  wound.  Regarding  this  operation,  Dr. 
Morton  says  :  "  It  is  noteworthy  in  this  case  that  the  anaesthetic 
effects  extended  at  least  one-half  an  inch  deep,  and  that  there 
were  no  toxic  effects  of  cocaine  (a  sixteen  per  cent,  solution  in 
guaiacol  was  used).  The  absence  of  toxic  effects  seems  to  me 
to  be  due  to  the  fact  that  the  guaiacol  holds  the  cocaine  in  solu- 
tion, thus  localizing  its  action  and  preventing  its  diffusion  into 

*  McKesson  &  Eobbius,  New  York. 


CONCLUSIONS.  383 

the  circulation.  This,  if  a  fact,  and  it  seems  to  be  one,  is  of 
the  highest  importance,  since  the  onl}'  objection  which  could  be 
raised  to  the  use  of  cocaine  so  extensively,  and  of  such  strength 
as  described  in  the  above  instance,  would  be  the  danger  of  the 
absorption  of  a  poisonous  dose,  especially  in  a  highly  vascular 
tissue,  such  as  the  naevus  operated  upon." 

Prof  Michaux,  in  speaking  of  local  anaesthesia,  recommended 
the  trial  of  the  new  combination  of  guaiacol  and  cocaine : 
"  Guaiacol  is  one  of  the  best  solvents  of  cocaine,  and  being  itself 
a  slight  local  anaesthetic  and  non-conductor,  it  intensifies  the 
action  of  the  cocaine.  It  is  also  more  profound  in  its  action 
and  is  deeply  penetrating.  Its  cataphoric  application  is  also 
said  to  consume  two-thirds  less  time  and  current  than  the  sim- 
ple cocaine  solution.  The  sixteen  per  cent,  solution  appears  to 
be  the  strength  most  commonly  preferred. 

"  Besides  producing  an  anaesthetic  condition  of  the  skin  and 
mucous  membrane,  it  has  been  used  with  perfect  success  for 
inducing  anaesthesia  of  sensitive  dentine." — University  College 
Bulletin. 

These  powerful  preparations  of  cocaine  are  not  free  from 
danger  when  used  on  soft  tissues,  or  even  on  sensitive  dentine 
where  leakage  through  the  rubber  dam  may  occur,  and  a  poison- 
ous dose  be  swallowed  which  might  prove  very  serious,  especially 
in  the  case  of  a  delicate  person. 


PART    SIXTH. 

LOCAL.  ANESTHETICS. 


CHAPTER    XIV. 

Coca  Plant,  Leaves — Preparations,  More  Especially  the  Wine  Made 
from  the  Leaves,  also  the  Active  Principle — Cocaine :  Its  Action 
as  a  Stimulant  of  the  Nervous  System  and  Eetarder  of  Meta- 
morphosis— Cocaine  and  its  Salts,  Solutions,  Tests  of  Purity — 
Cocaine  Inebriety  and  Habit,  Treatment — Death  from  Cocaine. 

Erytliroxyhn  Coca ;  Folia  Coca^.  The  Leaves.  Nat.  Order  : 
Eirythroxylacece.  Lamark.  U.  S.  P.  The  coca  is  a  small  tree 
four  to  six  feet  high,  indigenous  to  the  mountains  of  Peru  and 
Bolivia,  and  cultivated  in  both  these  countries  on  the  eastern 
slope  of  the  Andes,' in  damp,  warm  vallej^s.  The  leaves  are 
chewed  by  the  natives  to  satisfy  hunger,  to  strengthen  the  weak, 
to  stimulate  the  nerves  and  to  remove  depression  or  melan- 
choly. The  extract  obtained  by  alcohol  of  21°  and  56°  has  all 
the  gummy  and  resinous  principles  of  the  coca  leaf,  as  well  as 
the  fatty,  nitrogenous  principles,  the  tannin,  the  chlorophjd  and 
the  alkaloid.  It  is  this  extract  which  represents  best,  and  in 
exact  proportion,  the  constituent  principles  of  coca. 

Like  tea  and  coffee,  coca  is  used  in  nervous  headache,  and  as 
a  substitute  for  opium  in  opium  habit.  A  similar  use  has  sug- 
gested itself  in  the  treatment  of  alcoholism,  spermatorrhoea, 
generative  debility,  granular  pharyngitis  and  relaxation  of  the 
muscles  of  the  larynx,  pharynx  and  middle  ear. 

There  is  a  wine  of  coca  made  from  the  fresh  and  dry  leaves 
with  sherry  or  claret  wine. 


WINE    OF    COCA,    FROM    COCAINE. 
Plate  52— (Figs.  1-13)  * 


385 


Wine  of  Coca,  from  Cocaine. 

We  have  been  disappointed  in  the  results  of  the  administra- 
tion of  the  ordinary  wine  of  coca  in  the  market,  and  it  has  been 
suggested  the  preparing  of  this  wine  so  that  it  will  contain  a 
fixed  proportion  of  cocaine,  and  at  the  same  time  be  free  from 
the  tannin,  resin  and  other  inert  or  deleterious  substances  pres- 
ent in  the  leaves. 

To  a  good-bodied  wine— claret— add  two  and  a  half  grains  of 

-*The  entire  illustration  is  that  of  branch  with  young  foliage  and 
flowers.  No.  2,  entire  flower ;  between  2  and  3,  petal ;  4,  flower  with 
petals  removed;  5,  calyx  and  pistil ;  6,  vertical  section  ovary;  7  and 
8,  transverse  sections  ovary ;  9  and  10,  fruit ;  11,  transverse  section 
of  fruit ;  12,  section  of  stem  with  leaves  removed ;  13,  apex  of  leaf 


386  ARTIFICIAL    ANESTHESIA. 

the  hj^drochlorate  of  cocaine  to  the  pint,  the  dose  being  half  a 
wine-glassful,  which  will  contain  about  a  twenty-fourth  of  a 
grain,  repeated  at  each  meal.  We  have  found  this  wine  of  special 
value  as  a  tonic  to  the  vocal  apparatus,  or  in  cerebral  hyperae- 
mia,  the  result  of  excessive  mental  or  phj^sical  disturbance.  It 
has  also  been  found  useful  in  hysteria,  and  as  a  tonic  and 
stimulant  in  weakened  and  exhausted  nervous  system. 

Therapeutical  Uses  of  Coca  Leaves. 

We  have  employed  the  coca  and  found  it  useful,  first,  in  our 
own  case,  and  also  in  that  of  several  of  our  patients.  The  first 
efi"ect  of  our  experiments  with  the  wine  elixir  and  fluid  extract 
of  coca  in  full  doses  was  a  somewhat  irregular  muscular  action  or 
co-ordination,  and  if  given  in  large  doses  walking  becomes 
irregular.  Soon  after  the  moderate  dose  there  comes  a  feeling 
of  comfort,  and  as  the  effects  pass  off  there  is  a  slight  irregu- 
larity of  the  rhythm  of  the  heart.  This  is  followed  after  a  cer- 
tain time,  if  taken  at  night,  by  a  pleasant  sleep.  If  taken 
through  the  day  and  not  immediately  before  meals  by  a  person 
with  no  desire  for  food,  or  if  taken  after  meals,  it  passes  off 
before  the  next  regular  meal  and  the  appetite  is  not  affected. 
The  wine  was  the  first  preparation  recommended  to  us,  but 
after  using  that  made  in  this  city  with  sherry  wine,  we  found  it 
objectionable  to  certain  of  our  patients,  causing  headache  and 
dyspeptic  symptoms ;  so  that  in  Jefferson  Medical  College  Hos- 
pital we  resorted  to  a  preparation  of  claret  wine  or  the  fluid  ex- 
tract in  doses  of  sixty  drops,  three  times  a  day.  One  week  after, 
a  patient  with  tinnitus  reported  that  the  noises  were  much  less, 
throat  less  irritable,  and  it  was  possible  to  obtain  a  view  of  the 
vocal  cords,  which  were  found  white,  but  still  somewhat  relaxed 
in  the  act  of  phonation.  The  only  objection  to  its  continued  use 
in  this  form  was  the  constipation.  This  constipation,  it  is  stated 
by  our  patients,  does  not  follow  the  use  of  the  extract  made  with 
glycerine,  or  the  lime-water  infusion.  Still  the  peculiar  tannin 
which  it  contains  is  one  of  its  important  agents,  and  should  not 
be  omitted,  as  it  unites  with  the  active  principle  ;  therefore  it  is 
best  to  use  the  active  preparation,  for  the  constipation  can  be 
readily  obviated  by  adding  a  mild  laxative,  like  elixir  of  cascara. 


COCAINE    AND    ITS    SALTS.  387 

In  man  the  coca  diminishes  the  appetite  for  food  for  some 
hours,  and  at  the  same  time  greatly  increases  the  muscular 
strength  and  endurance.  The  celebrated  traveler,  "  Tschudi," 
found,  when  coca  leaves  were  taken  in  infusion,  it  conferred  a 
singular  immunity  from  suifering,  and  prevented  the  haemor- 
rhages which  were  apt  to  occur  in  the  elevated  passes  of  the 
Andes,  some  of  which  are  17,000  feet  high.  If  used  to  excess, 
coca  deranges  the  digestion  and  causes  habitual  constipation. 

Cocaine  and  Its  Salts. 

In  1855  Graedeke  discovered  in  coca  an  alkaloid  to  which  he 
gave  the  name  erythroxyline  ;  but  this  principle  was  first  thor- 
oughly studied  by  Dr.  Albert  Niemann,  from  whom  it  received 
the  name  cocaine,  as  an  anaesthetic,  but  first  used  in  the  eye  by 
Dr.  Karl  Koller,  of  Vienna. 

The  hydrated  alkaloid  cocaine  is  in  light,  white,  spongy  frag- 
ments, or  in  light  amorphous  powder,  very  much  like  magnesia. 
It  is  not  perfectly  white,  but  very  nearly  so.    It  is  nearly  insoluble 
in  water,  but  very  soluble  in  acids,  giving  solutions  that  are  not 
quite  colorless.     When  a  very  small  particle  is  laid  upon  the 
tongue,  and  the  tongue  then  held  against  the  roof  of  the  mouth, 
a  moderately  bitter  taste  is  perceived.     In  a  few  seconds  more 
the  bitterness  gives  place  to  numbness  and  insensibility  of  the 
surfaces,  as  though  scalded  by  hot  liquid,  except  that  there  is 
no  pain.     This  numbness  increases  for  a  few  minutes  and  then 
diminishes  slowlv,  and  disappears  in  from  ten  to  twenty  min- 
utes in  proportion  to  the  quantity  applied.     The  hydrochlorate 
of  cocaine  is  an  almost  white  crystalline  powder,  though  the 
fragments  of  crystals  are  so  small  that  it  appears  to  be  an 
amorphous  powder,  even  under  a  glass  of  low  power.     The 
powder  when  dry  is  loose   and  mobile,  but  when  exposed  to 
air  becomes  a  little  damp  and  clammy,  although  it  does  not  ap- 
pear to  be  deliquescent.     It  is  soluble  in  all  proportions  in  hot 
water,  in  alcohol,  and  in  somewhat  less  than  half  its  weight  of 
water  at  ordinary  temperatures.     Its  solutions  are  not  always 
colorless,  but  appear  to  be  nearly  so  when  seen  in  small  vials, 
even  up  to  the  strength  of  20  per  cent.     Solutions  of  50  or  60 
per  cent,  strength  are,  however,  of  a  greenish-yellow  tint.    The 


388  ARTIFICIAL    ANESTHESIA. 

solutions  are  neutral  to  test-paper.  When  tested  with  solution  of 
chloride  of  barium  thej''  give,  after  a  moment  or  two,  the  faint- 
est cloud  (limit  of  sulphates).  With  test  solution  of  oxalate  of 
ammonium  the  result  is  negative  (absence  of  lime).  When  the 
salt  is  burnt  on  a  platinum  surface  there  is  merely  a  trace  of 
residue  (limit  of  inorganic  matter),  and  the  spot  moistened  with 
water  scarcelj^  affects  the  color  of  neutral  litmus  paper  (limit  of 
inorganic  alkalies). 

According  to  Dr.  Niemann,  the  discoverer  of  cocaine,  the 
alkaloid,  when  heated  in  a  tube,  decomposes,  with  the  evolution 
of  a  dense  sublimate  of  benzoic  acid.  Wohler  and  Losson 
found,  upon  heating  cocaine  several  hours  in  a  sealed  glass  tube 
with  concentrated  hydrochloric  acid,  that  the  cocaine  resolved 
itself  into  benzoic  acid,  methyl  alcohol  and  ecognine. 

Cocaine  and  Its  Impiu'ities. 

The  presence  of  hygrine  and  ecognine  in  the  hydrochlorate  of 
cocaine  may  be  detected  by  treating  the  salt  with  cold  concen- 
trated sulphuric  acid.  If  the  salt  is  pure  the  result  is  a  com- 
pletely colorless  solution.    The  impurities  will  stain  the  solution. 

The  Instability  of  Cocaine. 

The  great  instability  of  cocaine  is  now  well  known,  the  simple 
contact  of  the  free  alkaloid  with  water  being  sufficient  to  decom- 
pose it.  The  hydrochlorate,  which  is  much  more  stable,  should 
be  absolutely  neutral ;  volatilized  completely,  forms  a  colorless 
or  slightly  turbid  solution  in  water,  gives  a  colorless  solution 
with  strong  sulphuric  acid,  and  should  not  reduce  permanganate 
of  potassium  immediately. 

Cocaine  has  the  composition  CnHsiNOi.  It  is  slightly  soluble 
in  water,  more  so  in  alcohol  and  freely  in  ether.  In  addition  to 
it  coca  leaves  contain  cocatannic  acid,  wax,  and  a  pale,  yellow, 
oily,  volatile  alkaloid,  hygrine.  Ecognine.,  which  is  obtained  by 
the  action  of  hydrochloric  acid  on  cocaine,  has  the  composition 
CgHisNOs,  and  is  insoluble  in  ether. 

We  had  found  it  valuable  in  affections  of  the  nose  and  ear, 
and  had  used  it  both  before  and  after  operation  in  a  5  to  10  per 
cent,  solution,  applied  with  a  brush. 


ACTION  OF  COCAINE  UPON  THE  ANIMAL  SYSTEM.       389 

The  test  for  cocaine  is  potassium  permanganate,  producing  a 
permanganate  salt,  and  when  heated  there  is  a  distinct  odor  of 
bitter  almonds. 

Chloride  of  gold  produces  a  distinct  precipitate  of  small  fern 
frond-shaped  crystals  arranged  in  stellate  groups.  A  solution 
of  iodide  of  potassium  and  picric  acid  produces  precipitates  of 
color,  etc.,  which  are  peculiar  to  cocaine.  The  physiological 
tests  are  its  anaesthetic  influence  on  the  eye,  dilatation  of  the 
pupil  and  benumbing  sensation  on  the  tongue. 

The  test  for  pure  cocaine  (Stockman's),  or  pure  hydrochlo- 
rate  of  pure  cocaine,  is  that  when  heated  with  strong  hydro- 
chloric acid  in  a  sealed  glass  tube,  in  the  water  bath,  it  splits 
up  into  its  components  without  any  change  of  color,  except  a 
very  light  yellow  tint  (from  the  HCI).  When  isatropylococine 
is  so  treated  it  splits  up  into  ecognine  and  a  brown,  oily-looking 
body,  which  is  decomposed  isatropic  acid.  The  anaesthetic  pro- 
perties of  cocaine  are  destroyed  by  boiling. 

Cocaine  salts  are  now  made  synthetically  on  a  large  scale. 


CHAPTER  XV. 

Experiments  with  Cocaine  on  Animals. 

The  Physiological  Action  of  Cocaine  Upon  the  Ani- 
mal System,  More  Especially  Upon  Dogs. 

Through  the  courtesy  of  Professor  Reichert,  of  the  Univer- 
sity of  Pennsylvania,  the  following  experiments  were  performed 
in  his  laboratory,  May  14,  1889  : 

A  dog,  weighing  8  pounds,  was  injected  with  1^^  grains  of 
Merck's  cocaine.  Pulse  172,  temperature  R.  38.9,  being  at  the 
rate  of  2  centigrammes  per  kilo.  Soon  after  he  became  rest- 
less, moving  his  tongue  in  and  out  of  his  mouth,  showing  an 
extra  secretion  of  saliva.  Then  followed  jerking  movements  of 
the  muscles,  more  especially  of  the  neck  and  head,  being  unable 
to  stand  on  his  feet,  as  though  intoxicated.    The  pupils  became 


890  ARTIFICIAL    ANESTHESIA. 

dilated,  balls  very  prominent  and  hard  from  increased  intraocu- 
lar pressure.  In  the  course  of  ten  minutes  or  more  convulsions 
supervened.  Temperature  increased  to  39.4°,  pulse  to  124. 
After  15  minutes  there  were  both  clonic  and  tonic  convulsions. 
His  bodily  movements  were  in  a  circle,  swaying  his  head  from 
side  to  side.  This  motion  of  the  head  continued  for  several 
hours — even  after  the  movement  of  the  limbs,  which  had  been 
lost,  had  been  regained.  A  pinch  was  felt,  showing  no  want  of 
reflex  excitability.  When  fully  under  the  influence  of  the 
cocaine  sight  and  hearing  seemed  unimpaired  until  convulsions 
set  in.  At  times  there  was  great  diSiculty  in  co-ordination,  but 
there  was  no  up  and  down  motion  of  the  head,  and  the  convul- 
sive motions  were  almost  always  rotary  and  to  and  fro. 

Second  Experiment. — Weight  16J  pounds,  pulse  120,  tem- 
perature 38.9°.  Dose  for  his  weight,  10  centigrammes.  A 
much  more  timid  animal  than  the  first,  and  after  15  minutes 
became  very  restless,  with  his  head  at  times  between  his  feet, 
having  a  weaving  motion,  his  mouth  making  a  snapping  move- 
ment. The  grain  and  a  half  of  cocaine  which  he  received  by 
injection  did  not  appear  to  produce  the  desired  intense  physio- 
logical efi"ects,  so  that  one  and  a  half  grains  extra  was  intro- 
duced over  the  spine.  Now  his  brain  became  evidently  very 
much  affected,  and  his  delirium  overcame  his  timidity.  When 
under  great  excitement  he  began  by  running  around  the  labo- 
ratory, battering  himself  at  intervals  against  anything  that  was 
in  his  way.  Respiration  increased,  causing  him  to  pant.  Ears 
were  thrown  back,  eyes  protruding,  balls  hard,  pupils  dilated, 
but  not  to  the  same  degree  as  the  first  animal. 

It  was  early  noticed  that  heat  is  increased  in  the  human  body 
by  the  use  of  cocaine.  In  1887,  Mosso,  of  Turin,  demonstrated 
by  experiment  that  this  drug  possessed  a  remarkable  power 
over  the  bodily  temperature,  raising  it  independently  of  convul- 
sions or  section  of  the  spinal  column^  and  this  is  owing,  accord- 
ing to  Mosso,  to  direct  changes  in  the  tissue,  or  the  action  of 
cocaine  on  the  heat  centres  supposed  to  exist  in  the  spinal  cord. 
These  facts  in  regard  to  the  section  of  the  spinal  cord  have  not 
been  confirmed  by  Professor  Reichert  (see  p.  53).  In  the  ex- 
periments of  Dr.  Hare  upon  dogs  only,  one  is  noted  as  having 


ACTION  OF  COCAINE  UPON  THE  ANIMAL  SYSTEM.       391 

violent  convulsions.  A  portion  of  cocaine  emplo5'ed  bj'  him 
varied  from  half  a  grain  in  a  dog  weighing  nine  pounds  to  three- 
quarters  of  a  grain  to  a  dog  weighing  seventeen  pounds.  In 
every  instance  the  cocaine  was  injected  into  the  jugular  vein. 
Animals,  like  human  beings,  are  affected  differentl}". 

The  following  are  the  most  recent  conclusions  of  Professor 
Reichert  on  the  action  of  cocaine  on  animal  heat  functions  : 
"  There  are  comparatively  few  drugs  known  to  therapeutists 
that  are  capable  of  causing  a  notable  increase  of  bodily  temper- 
ature, and  even  of  these  a  large  percentage  is  supposed  to  owe  this 
activity  largely  or  wholly  to  accompanying  motor  disturbances. 
It  is  at  least  a  curious  circumstance  that  all  poisons  which  ap- 
preciablj"  increase  temperature  are  pronounced  convulsants. 
Among  the  most  decided  of  the  phj'siological  actions  of  cocaine 
is  that  of  producing  a  rise  of  temperature  which,  even  in  mod- 
erate doses,  may  be  quite  remarkable.  Yon  Anrep*  states  that 
the  temperature  of  the  skin  was  always  decidedly  increased 
from  the  first,  while  the  rectal  temperature  at  the  same  time 
remained  unaltered,  or  was  decreased  from  0.5°  to  1°  C. ,  the 
latter  rising,  however,  during  the  convulsions,  to  a  similar  ex- 
tent. Danini  (quoted  bj^  Anrep)  notes  that  a  rise  amounting  to 
1°  C.  occurs  during,  and  is  dependent  upon,  the  convulsions. 
Mossof  always  observed  a  rise,  amounting  to  as  much  at  times 
as  3. 1°  C. ,  and,  contrary  to  Danini,  being  independent  of  con- 
vulsions, since  it  occurred  in  animals  rendered  motionless  by 
curare.  Hare,+  in  ten  experiments  in  which  the  drug  was  in- 
jected intravenously,  records  a  rise  varying  from  2°  to  7.5°  F. 
(1.11°  to  4.17°  C),  the  average  being  4.14°  F.  (2.3°  C).  Dose 
for  dose  the  action  is  more  powerful  and  prompt  when  intra- 
venously injected  than  when  hypodermatically." 

In  Reichert's  studies,  comprising  about  twentj^  experiments 
on  dogs,  a  marked  increase  was  always  noted.  "  In  all,  Merck's 
hydrochlorate  of  cocaine  was  used  and  injected  hypodermati- 
cally.    The  fatal  dose  in   dogs  is  about  0.03   gram  per  kilo. 

*  Pfluger's  Archiv.,  Bd.  XXI.  s.  68. 

t  Archiv.  f.  Exp.  Path.  u.  Phar.,  Bd.  XXIII.  s.  153. 

j  University  Medical  Magazine,  Vol.  I.,  p.  358. 


392  ARTIFICIAL    ANAESTHESIA. 

Doses  of  0.0025  gram  per  kilo  elicit  fairly  well-defined  symptoms 
of  cocaine  poisoning,  dilatation  of  the  pupils,  restlessness,  saliva- 
tion, increased  frequency  of  respiration,  more  frequent  and  for- 
cible pulse,  increased  temperature,  etc.  With  such  doses  the 
temperature  is  increased  about  from  0.2°  to  0.5°  C.  Doses  of 
0.01  gram  per  kilo  cause  a  rise  of  from  1°  to  2°  C.  Doses  of 
0.02  gram  per  kilo,  a  rise  of  from  2°  to  4°  C.  The  increase  is, 
however,  not  always  in  proportion  to  the  dose,  relatively  small 
doses  sometimes  causing  a  considerable  rise,  and  vice  versa. 
The  potency  of  cocaine  in  this  respect  is  altogether  remarkable, 
and  places  the  drug  in  the  foremost  rank  of  pyrogenic  agents ; 
indeed,  so  powerful  is  it  at  times  that  animals  suffer  from  heat 
dyspnoea.  Moreover,  the  action  is  one  of  notable  permanency, 
the  temperature,  after  large  but  sublethal  doses,  remaining 
above  normal  for  six  or  eight  hours  or  more. 

"Following  the  rise  of  temperature  and  subsequent  return  to 
the  normal,  a  fall  ensues,  which,  even  after  moderate  doses, 
lasts  for  some  hours. 

' '  The  results  of  my  experiments  are  not  in  accord  with  Von 
Anrep's  statements  above  referred  to,  since  in  every  instance  a 
marked  rise  of  temperature  occurred,  from  the  first  simultane- 
ously in  the  rectum  and  axilla  (skin),  the  thermometers  at  both 
points  of  observation  in  our  experiments  being  placed  in  posi- 
tion before  giving  the  drugs,  being  allowed  to  settle,  and  not 
being  removed  during  the  entire  time  of  observation.  The 
alterations  in  temperature  progressed  paH  passu  in  both  cases. 
The  rectal  temperature  rises  more  rapidly  than  that  of  the  skin, 
this  being  due,  to  a  large  extent,  if  not  wholly,  to  the  quicker 
reaction  of  the  thermometer  in  the  former  position.  The  ther- 
mometers used,  when  placed  in  the  rectum,  settle  in  from  three 
to  five  minutes,  but  from  ten  to  fifteen  minutes  are  required  in 
the  axilla,  although  the  thermometers  were  identical  in  make 
and  sensitiveness."  We  cannot  give  the  full  details  of  Dr. 
Reichert's  experiments,  but  he  showed  that  a  rise  in  tempera- 
ture does  not  occur  after  section  of  the  spinal  cord. 

We  have  shown  by  the  above  experiments  on  dogs  the  action 
of  cocaine. 


FATAL    DOSE    OF    HYDROCHLORATE    OF    COCAINE.       393 

On  the  Actiou  of  Cocaine  on  the  Eye. 

When  introduced  into  the  eye,  it  causes  local  anassthesia, 
with  dilatation  of  the  pupil,  paralysis  of  accommodation,  slight 
lachrymation,  and  enlargement  of  the  palpebral  fissure. 

When  injected  into  the  back  of  the  orbit,  it  causes  protrusion 
of  the  eyeball.  Its  effects  appear  to  be  due  to  stimulation  of 
the  peripheral  ends  of  the  sympathetic.  Subcutaneous  injec- 
tions also  produce  local  anaesthesia  at  the  point  of  application, 
so  that  subsequent  irritation  at  that  spot  produces  no  sensation 
in  man  and  no  reflex  action  in  animals.  When  taken  internally, 
it  appears  to  have  in  small  doses  a  stimulating,  and  in  large 
doses  a  paralyzing  action  on  the  nerve  centres.  It  affects  first 
the  cerebral  hemisphere,  next  the  medulla,  and  afterwards  the 
spinal  cord. 

The  writer  has  performed  numerous  experiments  on  himself 
and  others  to  determine  the  action  of  the  alkaloid  cocaine  and 
its  chief  salt,  the  hydrochlorate. 

In  moderate  doses  of  the  hydrochlorate  it  can  be  adminis- 
tered in  from  one-fifth  to  even  one-quarter  of  a  grain  every 
hour,  until  the  patient  is  relieved,  or  the  peculiar  constitutional 
symptoms  show  themselves,  these  doses  acting  as  a  stimulant 
on  the  peripheral  ends  of  the  sympathetic.  In  larger  doses  it 
has  an  action  on  the  nerve  centres,  affecting  first  the  cerebrum, 
next  the  medulla,  afterwards  the  spinal  cord.  If  employed  in 
still  larger  doses  there  is  intense  exhilaration,  or  intoxication, 
more  or  less  loss  of  consciousness,  followed  by  palpitation  and 
even  death,  although  this  is  rare.  I  have  seen  no  deaths  from 
cocaine  for  the  last  six  years  in  Philadelphia. 

Fatal  Dose  of  Hydrochlorate  of  Cocaine. 

Peculiar  effects  :  A  nervous  thrill  or  tingling  sensation,  in- 
crease of  pulse,  dryness  of  the  tongue,  relief  of  pain  or  gastric 
disturbance,  sensation  of  fulness  in  the  head  or  heat  of  the 
face,  at  times  producing  wakefulness,  followed  by  frontal  head- 
ache ;  in  other  cases  there  is  dilatation  of  the  pupil,  with  a 
tendency  to  sleep,  the  patient  awaking  in  his  ordinary  condi- 
tion of  mind.     If  larger  doses  are  required,  the  symptoms  are 

26 


394  ARTIFICIAL    ANAESTHESIA. 

similar  in  character,  only  increased  in  intensity,  great  mental 
excitement,  increased  irregularity  in  rhythm  or  force  of  the 
heart,  insomnia,  or  being  unable  to  sleep,  and  invariably  head- 
ache the  following  morning. 

The  fatal  dose  is  usually  from  six  to  ten  grains,  but  from 
idiosyncrasy  or  peculiarity  of  constitution  a  much  smaller  dose 
may  prove  fatal.  Dr.  Hammond,  of  New  York,  took  very 
much  larger  doses.  Before  the  last  injection  the  pulsations  of 
the  heart  were  140  to  the  minute,  and  characteristically  irregu- 
lar. He  found  his  mind  passing  beyond  his  control,  and  he 
was  becoming  an  irresponsible  agent.  He  lost  all  conscious- 
ness half  an  hour  after  administering  the  last  dose,  remaining 
so  until  nine  o'clock  next  morning,  when  he  awoke  with  an  in- 
tense headache  with  a  great  deal  of  cardiac  and  respiratory  dis- 
turbance. 

No  marked  influence  appeared  to  be  exercised  upon  his  spinal 
cord  or  upon  the  ganglia  at  the  base  of  the  brain. 

There  were  no  disturbances  of  sensibility  (no  anaesthesia,  no 
hyperaesthesia),  and  no  interference  with  mobility  except  that 
some  of  the  muscles,  especially  those  of  the  face,  were  subjected 
to  slight  twitchings. 

In  regard  to  sight  and  hearing  he  noticed  that  both  were 
affected ;  but  that  while  the  sharpness  of  vision  was  decidedly 
lessened,  the  hearing  was  increased  in  acuteness.  At  no  time 
were  there  any  hallucinations. 

The  exciting  action  of  cocaine  on  the  brain  is  extremely 
prominent  among  its  physiological  peculiarities — much  more  so 
than  its  anaesthetic  influence. 

1.  The  first  noticeable  effect  on  the  lower  animals  is  restless- 
ness, gradually  increasing  to  more  or  less  intense  excitement. 

2.  In  animals  the  cerebellum  is  more  or  less  affected. 

3.  Chloral  is  certainly  antagonistic — so  with  chloroform,  also 
ether — during  anaesthetic  stage,  but  not  during  its  primary  stage 
of  excitement. 

4.  There  is  some  evidence  to  indicate  that  the  semi-circular 
canals  are  affected,  as  shown  by  the  vertiginous  movements. 

5.  In  poisonous  doses  the  convulsions  seem  to  be  both  of 
cerebral  and  spinal  origin,  but  chiefly  cerebral. 


COCAINE    INEBRIATION    AND    HABIT.    ^  395 

6.  The  motor  or  sensory  nerves  do  not  seem  to  be  affected 
until  late  in  the  poisoning. 

7.  The  action  on  circulation  is  complex  ;  pneumogastric  nerves 
primarily  stimulated,  secondarily  depressed.  Blood  pressure 
similarly  affected.  Therapeutic  doses  probably  act  as  circula- 
tory stimulant. 

8.  The  pupils  in  all  of  the  experiments  were  dilated  and 
intra-ocular  pressure  increased.  We  have  never  noticed  any, 
injurious  effects  on  animals  in  any  way  after  using  non-lethal 
doses.  The}'  naturally  suffer  some  after-depression  because  of 
the  intense  mental  and  muscular  excitement  during  the  action 
of  the  poison, 

9.  Bodil}'  temperature  is  increased. 

10.  Tissue  metamorphosis,  as  is  indicated  by  Dr.  Reichert's 
experiments,  is  probably  increased. 

11.  The  fatal  dose  for  animals  is  about  0.03  grammes  per 
kilo  of  bod}'^  weight.  The  fatal  dose  for  man  varies  within  very 
wide  limits. 

12.  It  is  claimed  that  it  at  times  interferes  with  the  healing 
of  the  wound  after  operations,  and  to  be  less  efficient  on  other 
membranes  than  the  conjunctiva. 


CHAPTER    XVI. 

Cocaine  Inebriation  and  Habit — Treatment — Deaths  from  Cocaine — 
Morbid  Changes  in  Poisoning  by  Cocaine. 

In  the  cases  under  Dr.  Crother's  care  a  correct  history  was 
obtained;  in  the  five  cases  who  sought  advice  by  person  and 
letter  their  own  personal  statements  were  the  chief  sources  of 
information.  In  two  cases  statements  were  confirmed  by  others, 
and  where  such  statements  corresponded  with  the  facts  in  other 
cases,  they  were  accepted  as  probably  true.  The  following  are 
some  of  the  facts  which  appeared  from  the  history  of  these 
cases : 


396  ARTIFICIAL    ANJ3STHESIA. 

Alcohol,  opium,  chloral,  bromides  and  other  narcotics  had 
been  used  more  or  less  to  excess  in  all  these  cases  before  co- 
caine was  taken.  In  four  of  these  cases  coca  had  been  used 
for  months  before  cocaine  was  tried.  Hence  they  were  all 
literally  drug  maniacs,  or  inebriates,  whose  special  symptom  of 
disease  is  a  morbid  impulse  for  narcotic  drugs,  which  will  bring 
rest  and  relief  to  the  organism.  He  is  also  persuaded  to  be- 
lieve that  cocaine  inebriety,  or  coca  mania,  will  never  become 
prominent,  and  will  be  confined  to  a  class  of  neurotics  who,  by 
the  use  of  other  drugs,  have  prepared  the  soil  for  this  new 
drug-mania.  It  will  never  take  the  place  of  alcohol  or  opium 
in  common  use.  Its  action  is  too  uncertain  and  transient.  The 
present  novelty  and  glamour  about  its  effects  will  die  away 
when  its  real  value  is  ascertained.  The  element  of  contagion 
in  these  cases  presents  a  curious  psychological  phase  ;  thus 
some  extravagant  newspaper  statement  of  the  terrible  effects  of 
this  drug  will  rouse  curiosity  to  test  it,  or  the  printed  history 
of  a  case  appearing  as  daily  news  draws  the  attention  of  neu- 
rotics, and  it  is  safe  to  say  that  a  large  per  cent,  not  only  pur- 
chase, but  test  this  drug  on  themselves.  Cocaine  should  not 
be  used  as  a  substitute  in  breaking  away  from  the  use  of  other 
narcotics.  It  should  not  be  used  in  large  or  long-continued 
doses.  It  cannot  be  used  indiscriminately.  However  valuable 
it  may  be,  there  is  a  cer.tain  limit  to  its  power  and  practical 
use. 

The  treatment  of  cocaine  inebriety  is  the  same  as  that  of  alco- 
hol or  opium  cases.  Forced  abstinence  from  the  di^g,  rest  and 
building  up  the  system  are  the  general  methods  pursued.  More 
profound  degeneration  and  debility  exist  than  in  other  forms 
of  inebriety,  requiring  a  longer  time  for  successful  treatment. 
Clouston  {Edinh.  Med.  Jour.,  1891)  advises  stopping  the  drug, 
careful  watching,  nursing,  the  use  of  every  sort  of  food  that 
will  keep  up  the  strength,  and  of  the  bromide  of  ammonium, 
brandy  or  wine,  tea  and  coffee,  and  possibly  a  hypnotic,  like 
paraldehyde  or  sulphonal,  for  at  least  two  or  three  nights. 

States  of  mania  and  melancholy  often  continue  for  some 
time  after  the  use  of  the  drug  is  given  up,  and  disappear  very 
slowly.     It  is   for  these  states  that  special  surroundings  and 


TREATMENT  OF  NERVOUS  SYMPTOMS.      397 

care  are  essential.  The  prognosis  is  alwaj^s  uncertain.  The 
craving  for  drugs  that  their  effects  may  be  broken  up  and  res- 
toration follow ;  but  such  cases  generally  are  unable  to  bear 
much  exposure,  and  not  unfrequently  relapse  on  the  slightest 
temptation. 

On  making  inquiry  of  Dr.  Osier,  now  of  Baltimore,  one  of 
the  attending  physicians  of  the  largest  hospital  in  Philadelphia, 
as  to  how  many  cases  he  had  ever  seen  of  cocaine  habit,  he 
stated  but  one  or  two,  and  of  opium  or  morphia  habit,  during 
his  term  of  service  of  four  months,  there  were  but  four  cases. 
In  what  dose  did  he  give  cocaine  ?  As  a  rule,  one-quarter  of  a 
grain  was  the  usual  dose,  and  the  strength  of  the  solution  for 
hypodermic  application  was  two  per  cent.  If  this  rule  is  fol- 
lowed, we  think  that  it  is  as  safe  as  morphine,  atropine  and 
agents  of  a  like  character. 

Treatment  of  Nervous  Symptoms  from  Cocaine. 

Should  nervous  symptoms  occur,  such  as  temporary  deafness, 
blindness,  loss  of  taste  or  smell,  place  the  patient  on  a  lounge 
or  sofa,  open  the  windows  and  admit  plenty  of  pure  air,  then 
employ  from  five  to  ten  drops  of  the  nitrate  of  amjl  in  capsules, 
broken  on  a  handkerchief,  to  be  inhaled  by  the  nostrils.  Should 
the  patient  become  covered  with  cold  perspiration,  livid  in  color, 
apply  dry  friction  to  the  skin,  with  twenty  drops  of  aromatic 
spirits  of  ammonia,  in  water,  repeated  at  intervals.  Should 
the  patient  suffer  from  gastric  cramps,  give  a  teaspoonful  of 
compound  spirits  of  lavender,  or,  if  not  relieved,  brandy.  Use 
morphine,  hypodermically,  one-eighth  of  a  grain.  If  the  pulse 
be  irregular  or  intermittent,  with  shallow,  gasping,  irregular, 
convulsive  or  suspended  breathing,  artificial  respiration  should 
be  resorted  to,  with  hypodermic  injections  of  ether  or  chlo- 
roform, and  even  the  galvanic  battery,  to  prevent  a  fatal 
result. 

In  cases  of  poisoning,  the  nitrate  of  amyl  is  considered  the 
best  antidote.  Claude  Bernard  has  demonstrated  by  his  experi- 
ments that  cocaine,  in  its  action  on  the  cerebral  circulation,  was 
exactly  the  antagonist  of  nitrate  of  amyl.  Under  the  effects  of 
amyl,  the  cerebral  arteries  contract,  anaemia  of  the  brain  de- 


398  ARTIFICIAL    ANAESTHESIA. 

velops,  the  arterial  pressure  is  increased  and  the  face  looks 
pale.  Cocaine  causes  a  dilatation  of  the  vessels  of  the  heart, 
hyperaemia,  with  diminished  arterial  pressure,  sets  in,  in  the 
encephalon,  and  the  face  appears  flushed  and  in  a  general  state 
of  venous  congestion.  Cocaine  is  antagonistic  in  its  action  to 
ether  and  chloroform.  The  convulsive  seizures  induced  by  the 
action  of  poisonous  doses  of  cocaine  can  be  at  once  allayed  by 
the  inhalation  of  either  of  these  agents.  In  cases  of  cocaine 
poisoning  in  man,  we  therefore  recommend  that  ether  or  chlo- 
roform should  be  administered  to  allay  the  first  and  severer 
symptoms,  chloral  being  afterward  given  in  small  doses  to  keep 
up  the  effect. 

We  were  highly  delighted  to  find,  from  a  pamphlet  of  Prof. 
Viau,*  that  he  had  been  able  to  modify  the  hydrochlorate  of 
cocaine  in  solution  with  pure  phenol,  gr.  ij.,  to  cocaine,  gr.  iv. , 
to  100  grs.  distilled  water,  so  as  to  prevent,  in  87  cases,  any  un- 
pleasant results  from  its  use  in  the  extraction  of  teeth.  This 
solution  was  prepared  as  directed  by  the  Paris  dental  surgeon  : 

^>    Crystallized  xjlienic  acid,        .        .        .    gr.  j. 

Cocaine,  pure, grs.  ij. 

Distilled  water, grs.  100.     M. 

Sol.  aad  filter.     Make  each  time  that  it  is  employed. 

And  before  a  class  of  about  200  students  the  mixture  was  in- 
jected into  the  jaw  in  a  case  of  diseased  antrum  in  a  young  lady. 
She  was  then  operated  upon  by  Dr.  Garretson,  who  removed 
the  diseased  bone  with  the  dental  engine.  She  bore  the  opera- 
tion with  great  equanimity,  and  with  so  little  pain  as  to  be  un- 
noticed by  the  students ;  and  when  asked,  at  the  completion  of 
the  operation,  she  stated  that  she  experienced  some  slight  pain. 
The  case  was  an  interesting  one  in  its  freedom  from  excitement 
and  haste,  and  the  quiet  way  in  which  she  would  rise,  expec- 
torate the  blood  and  be  cleansed  from  the  horrible  disfigure- 
ment, avoiding  the  great  risk  produced  by  profound  anaesthesia, 
which  is  so  nigh  unto  death,  required  in  such  an  important 
operation. 

'-■•  Monograph,  by  Prof.  George  Viau,  Paris,  1892. 


schleich's  infiltration  method.  399 

Sclileich's  Infiltration  Method  of  Local  Angestliesia 

by  Cocaine.* 

Dr.  H.  y.  Wiirdemann  was  the  first  to  use  the  method  of 
"Schleich"  in  the  United  States,  and  gives  the  following  im- 
portant testimony  in  favor  of  this  metliod  :  "He  has  personally 
done  half  a  hundred  operations  upon  the  eyelids,  etc.,  by  this 
form  of  anaesthesia,  as  well  as  various  operations  upon  other 
parts  of  the  body  while  prosecuting  his  original  investigations. 
He  also  assisted  at  a  number  of  operations,  as  ovarian  tumors, 
amputations,  hernias — to  all  the  minor  operations." 

Schleich,  in  an  extensive  use  of  his  method  for  at  least  one 
year,  makes  the  following  statement,  that  local  anaesthesia  with 
cocaine  can  be  employed  successfully  in  ninety  per  cent,  in  all 
operations.  Another  advantage  he  claims  is  the  rapidity  of  its 
application  and  the  short  time  in  the  preparation  of  the  patient, 
and  the  safety,  if  his  rules  are  carried  out.  Again,  the  after-, 
effects,  as  vomiting  and  depression,  are  much  more  rare.  As 
we  have  already  stated,  he  employs  various  strengths  of  the 
solution.  He  seems  to  prefer  the  medium  strength  of  solution, 
which  has  but  one  part,  with  two  parts  of  sterilized  chloride  of 
sodium  to  one  thousand.  If  the  skin  is  very  sensitive  to  the 
puncture  of  the  needle,  the  part  is  sprayed  by  ethyl  chloride  ; 
or,  if  it  is  in  a  mucous  surface,  by  the  five  per  cent,  solution  of 
carbolic  acid.  A  free  application  of  glycerine  over  all  surround- 
ing parts  is  also  highly  recommended. 

It  must  be  particularly  remarked  that  the  infiltration  on  one 
spot  lasts  from  fifteen  to  twenty  minutes,  and  should  it  be 
found  necessary  to  return  to  such  a  spot  at  the  expiration  of 
this  time,  a  fresh  infiltration  would  be  necessary.  In  this  way 
we  may  operate  for  hours  on  the  same  spot. 

It  must  also  be  remembered,  that  after  the  period  above 
mentioned,  the  parts  of  skin  which  have  been  held  back  during 
the  operation,  must  be  anaesthetized  over  again,  and  care  should 
be  taken  to  make  the  wheals  large  enough  to  allow  space  for 
the  thread  and  knots,  one  method  being  to  produce   one  on 

*  The  Infiltration  Method  of  Anaesthesia.  Eeprint  Am.  Med.  Asso.. 
November  16.  1895. 


400  ARTIFICIAL    AN.57.STHESIA. 

each  side  of  the  separated  cuticle,   and  draw  the  needle  and 
thread  through  the  centre  of  these. 

Inflamed  Parts. 

There  is  a  great  difference  of  sensibility  in  the  anaesthetizing 
of  a  normal  part,  or  of  a  highly  sensitive  one,  such  as  inflamed 
parts  by  abscess,  tumors,  etc.  In  these  cases  it  is  absolutely 
necessary  to  start  the  anaesthesia  in  the  healthy  parts.  Begin 
the  infiltration  far  back  from  the  seat  of  inflammation,  and  in- 
sert the  needle  through  the  first-formed  wheal  gradually,  while 
pressing  steadily  on  the  piston,  deep  into  the  part  toward  the 
seat,  emptying  the  syringe  all  outside  of  the  inflamed  zone. 

In  this  way  the  infiltration  is  carried  on  from  the  four  oppo- 
site points  at  first,  and  then  only  gradually  the  upper  cuticle  is 
treated,  and  this  also  beginning  first  in  the  healthy  region. 

In  this  way  wheal  after  wheal  is  formed  until  the  whole  of 
the  inflamed  part  is  saturated,  which  can  be  readily  observed 
by  the  disappearance  of  the  red  inflamed  color  and  its  substitu- 
tion by  the  white  zone  of  the  infiltration. 

The  best  action  of  this  form  of  anaesthesia  has  been  found  on 
parts  like  the  fingers  or  toes  or  penis.  The  return  circulation 
can  be  interrupted  by  circular  constriction,  and  the  entire 
quantity  can  be  retained. 

Corning  has  used  hard  rings  pressed  upon  flat  skin-areas  in 
order  to  similarly  interrupt  the  circulation  of  the  fluids  that  tend 
to  carry  away  the  anaesthetizing  substance.  Under  this  practice 
there  are  three  zones  of  sensory  nerve-activity — a  zone  of  com- 
plete anaesthesia  corresponding  to  the  area  in  which  the  cocaine 
is  in  sufficient  concentration  to  completelj'^  overcome  the  sensi- 
bility of  the  nerve-endings  and  filaments,  a  zone  in  which  sensa- 
tion is  partially  inhibited,  and  an  area  in  which  the  anaesthesia 
gradually  fades  away. 

It  was  easily  seen  that  if  by  osmosis  or  by  the  mechanical 
movement  of  fluids  the  cocaine  was  brought  into  contact  with 
all  the  nerve-structures  in  approximately  one  degree  of  concen- 
tration, and  if  this  contraction  were  exactly  that  required  to 
inhibit  nerve-action,  the  desired  result  would  be  accomplished 
with  a  minimum  quantity  of  the  drug. 


INFLAMED    PARTS.  401 

Liebericli  ami  Wiirdemaiin  have  shown,  however,  that  the  in- 
jection of  simple  water  into  the  tissues  in  such  a  way  as  to  pro- 
duce an  artificial  oedema  will  induce,  with  some  discomfort,  a 
transitory  anaesthesia.  C.  L.  Schleich  found  that  by  combining 
a  small  quantity  of  cocaine  with  a  weak  salt-solution,  the  dis- 
comfort was  removed  and  the  anaesthesia  prolonged  ;  and  it  only 
remained  to  add  a  little  morphine  to  the  solution  to  prolong  the 
beneficent  action  sufficiently  to  give  opportunity  for  the  perform- 
ance of  surgical  operations.  Some  surgeons  add  a  minute  quan- 
tity of  atropine.  Complete  anaesthesia  depends,  in  this  method, 
upon  the  artificial  ischaemia  established,  and  upon  the  high 
pressure  to  which  the  tissues  are  subjected  ;  also  upon  the  low- 
ered temperature  brought  about  b^^  the  introduction  of  the  cool 
water;  and  finally  upon  the  direct  action  of  the  anaesthetizing 
drugs.  Leaving  aside  alleged  personal  disinclination  on  the  part 
of  European  clinicians  to  adopt  the  method  of  Dr.  Schleich,  it 
seems  to  me  that  the  failure  of  the  infiltration-method  up  to  the 
present  time  to  become  popular,  depends  upon  the  fact  that  a 
special  technic  is  required.  This  technic  is,  however,  so  simple 
and  easy  that  x^merican  physicians,  I  am  sure,  need  only  read 
an  account  of  it  to  understand  and  practice  it.  And,  as  local 
anaesthesia  can  be  induced  by  it  in  a  few  moments  for  the 
opening  of  abscesses,  furuncles,  or  carbuncles,  for  the  removal 
of  a  prepuce,  or  for  the  amputation  of  fingers,  or  even  of  the 
forearm,  with  the  use  of  a  solution  of  one  part  of  cocaine  in  a 
thousand  of  water^  every  intelligent  worker  must  grant  its  ad- 
vantages and  apply  it  in  practice.  The  hypodermic  syringe 
which  he  employs  is  larger  and  the  needles  longer,  and  of  vari- 
ous lengths,  being  straight  and  curved.  It  has  been  suggested 
to  have  an  asbestos  packing.  These  needles  are  always  kept 
ready  for  use  in  an  antiseptic  solution  of  carbolic  acid.  The 
parts  before  operation  should  be  shaved,  and  all  hair  removed, 
except  in  the  eyelashes  or  eyebrows,  and  should  be  well  washed 
with  Castile  soap  and  hot  water,  followed  by  alcohol,  and  last — 
but  not  least  in  importance — a  solution  of  one  to  five  thousand 
of  bichloride  of  mercury. 

The  following  formulas  are  advocated  by  Schleich  :* 

""■■  Translation  by  Dr.  H.  V.  Wiirdemann.     Pamphlet,  p.  3. 


402  ARTIFICIAL    ANJ3STHESIA. 


Cocaine  mur., 


Morph.  mur.,   . 
Natr.  chlor.,     . 
Aqu.  dest.  ad., 
M.  Sterilisat.  adde.  sol,  ac 


carbol.  5  per  cent 


.20 
.025 
.20 
100. 
gtt.  ij. 


S.    Solution  No.  1,  strong.     For  operating  upon  highly 
inflamed  or  hyperesthetic  areas. 

^    Cocaine  mur., .10 

Morph.  mur., .025 

Natr.  chlor., .  .20 

Aqu.  dest.  ad.,  .         .         .         .         .         .     100. 

M.  Sterilisat.  adde.  ac.  carbol.  5  per  cent.  gtt.  ij. 

S.    Solution  No.  2,  medium.     For  most  operations. 

^     Cocaine  mur., .01 

Morph.  mur., .005 

Natr.  chlor., .20 

Aqu.  dest.  ad., 100. 

M.  Sterilisat.  adde.  sol.  ac.  carbol.  5  per  cent.  gtt.  ij. 

S.    Solution  No.  3,  weak.     For  superficial  operations 
upon  nearly  normal  tissues. 

All  are  to  be  kept  strictl}^  sterile  ;  glass  stoppers  or  scorched 
cotton,  such  as  are  used  in  bacteriologic  experiments  for  the 
bottles  ;  small  quantities  to  be  poured  out  in  smaller  vessels  for 
each  operation.  Just  before  operation  the  solution  should  be 
cooled  by  laying  the  bottle  containing  it  on  ice.  The  common 
form  of  hypodermatic  syringe  with  the  finest  of  needles  is  all 
that  is  usually  needed.  Dr.  Chas.  Denison,  of  Denver,  Colo. , 
has  given  us  an  aseptible  syringe  of  larger  capacity,  with  piston 
packing  of  asbestos,  which  is  particularly  applicable  for  aseptic 
injection.  The  syringe  is  kept  in  good  order  by  being  fre- 
quently soaked  in  a  five  per  cent,  carbolic  solution  and  the 
needle  sterilized  after  each  operation. 

The  discovery  of  these  truths,  so  valuable  for  the  question  of 
local  anaesthesia,  is  due  simply  to  a  slight  change  of  method — 
the  application  of  the  solution  within   and  not  under  the  skin. 
The  anaesthesia  is  caused  by  the  replacement  of  the  normal 
fluids  of  the  tissues  by  a  fluid  of  less  specific  gravity  (the  water), 


THE    TECHNIQUE    OF    LOCAL    ANAESTHESIA.        403 

which  causes  anaemia,  compression  and  cooling,  producing 
thereby  a  temporary  paralysis  of  the  nerve  filaments.  The 
pain  of  the  infiltration  of  indifferent  solutions  is  abolished  by 
the  minute  doses  of  narcotic  drugs  (morph.,  cocaine,  carb.  ac). 
"  It  is  perhaps  well  to  here  go  into  the  technique  of  the  pro- 
duction of  local  anaesthesia  by  this  method.  The  field  of  oper- 
ation is  made  aseptic  in  the  usual  manner.  Having  the  re- 
quired formula,  the  solution  aseptic  and  cold,  we  fill  the 
sterilized  hypodermic  syringe,  pinching  the  skin  slightly  be- 
tween the  thumb  and  forefinger  of  the  left  hand  ;  the  needle  is 
then  passed  obliquely  under  the  epidermis  to  the  papillae,  intra- 

Plate  53. 


Diagram  of  a  section  of  the  skin,  showing  formation  of  the  first 

wheal. 


cutaneously,  until  the  lumen  is  fully  inserted.  A  few  drops  are 
then  injected,  thereby  producing  a  white  elevated  wheal,  the 
infiltration  extending  throughout  the  whole  thickness  of  the 
skin.  (See  Plate  53.)  There  is  immediate  and  complete  anaes- 
thesia throughout  the  extent  of  the  infiltration,  which  lasts 
from  ten  to  twenty  minutes,  according  to  the  density  of  the 
tissue  so  oedematized.  The  needle  is  then  re-inserted  at  the 
periphery  of  the  wheal,  and  the  area  infiltrated  to  the  required 
extent  and  depth.  No  tissue  offers  any  deviation  from  the 
dictum ;  every  structure  is  made  anaesthetic  that  can  be  arti- 
ficially oedematized :  this  holds  good  for  skin,  mucous  and 
synovial  membrane,  periosteum,  fascia,  muscle,  lymph  glands, 
nerves,  viscera,  and  even  bone." 


404 


ARTIFICIAL    ANESTHESIA. 


Anaesthesia  exists  only  within  the  area  infiltrated  by  the  solu- 
tion, and  outside  of  that  normal  sensation  remains.  In  opera- 
tions on  or  through  the  skin  and  mucous  membranes,  the  first 
wheal  is  increased  to  the  size  of  a  dime  by  increased  pressure 
on  the  piston ;  the  needle  is  moved  and  re-inserted  at  the 
periphery  of  the  wheal,  but  still  within  it,  and  a  new  wheal 


Plate  54, 


Formation  of  the  cutaneous  wheals. 


raised.  In  this  way  the  line  of  incision  is  marked  out  to  any 
desired  length  or  breadth.  (See  Plate  54.)  In  general  surgical 
operations  we  would  then  infiltrate  the  underlying  tissues  by 
slowly  pushing  in  the  needle  and  injecting  a  few  drops  at  a  time 
until  the  deeper  tissue  is  oedematized. 

By  cooling  the  spot  selected  for  the  formation  of  the  first 
wheal  by  ether  or  rhigolene  spray,  or,  on  mucous  membranes, 
by  touching  the  spot  with  a  strong  solution  of  carbolic  acid  or 


NOTES  ON  THE  DANGER  OF  SEPSIS.      405 

applying  cocaine,  the  first  injection  may  be  made,  if  so  desired, 
without  even  feeling  the  prick  of  the  needle.  This  is  seldom 
necessary,  as  a  very  fine  needle  may  be  inserted  without  pain 
even  in  very  tender  tissues,  such  as  the  eyelids.  The  succeeding 
injections  may  now  be  made  without  causing  sensation.  There 
is  no  sensation  to  the  infiltration  proper. 

Where  the  tissues  are  inflamed,  the  sensibility  is  pathologi- 
cally increased.  Here  it  is  indispensable  that  the  infiltration  be 
begun  in  sound  tissue  and  carried  over  into  the  part  to  be  oper- 
ated upon.  The  dilated  blood  and  lymph  channels  of  the 
inflamed  skin  allow  us  to  anaesthetize  quite  a  large  spot  from 
one  puncture. 

The  injection  should  be  done  slowly  at  first,  and  when  the  in- 
filtration is  only  felt  by  its  tension  we  may  rapidly  flood  the  part 
to  the  required  extent.  Under  no  circumstances  must  the  fluid 
be  primarily  injected  into  an  abscess,  an  exudation  or  a  patho- 
logic focus.  The  only  result  is  increased  tension  and  pain.  We 
must  not  lose  sight  of  the  cardinal  fact  that  the  anaesthesia 
exists  only  within  the  area  infiltrated  by  these  solutions,  and  that 
outside  of  that  there  is  normal  sensation.  The  method  rests 
principally  on  the  production  of  a  complete  artificial  cedema  of 
the  tissues.  Wherever  we  wish  to  operate  with  exact  anaesthe- 
sia, the  field  of  operation  must  be  tensely  filled  with  the  solu- 
tion, so  that  it  exudes  from  the  cut  surface. 

The  following  important  caution  Dr.  Wiirdemann  has  pub- 
lished as  late  as  February,  1896,  and  has  kindly  placed  it  at  our 
disposal : 

Notes  on  the  Danger  of  Sepsis  in  Endermatic 
Injection  (Infiltration  Anaesthesia).* 

"The  growing  popularity  of  infiltration  anaesthesia  since  its 
discovery,  in  1891,  by  Schleich,  of  Berlin,  and  subsequent  in- 
troduction into  Germany  and  America  one  and  a  half  years  ago, 
leads  me  to  sound  a  note  of  warning  regarding  its  indiscriminate 
use  without  proper  care  as  to  the  technique.  The  only  substan- 
tial objection  to  this  form  of  local  anaesthesia  that  has  been 

*  See  editorial  in  Medical  News,  February,  1896. 


406  ARTIFICIAL    ANAESTHESIA. 

heretofore  raised  is  that  of  the  possibility  of  infection  from 
septic  fluids,  unclean  hands  or  instruments. 

"There  are  certainly  many  physicians  who  either  do  not  clean 
their  hypodermatic  syringes  or  simply  wipe  them  off,  and  then 
go  to  the  next  patient.  It  is  not  customary  to  make  special 
preparation  of  the  skin,  or  of  the  hypodermatic  needle,  for  ordi- 
nary hypodermatic  injection.  Even  the  fluid  used  in  which  to 
dissolve  the  morphine,  etc. ,  tablet  is  not  always  drawn  from  an 
aseptic  source.  The  small  amount  of  serum  which  clings  to 
the  needle  on  withdrawal  is  certainly  a  culture  medium  for  the 
streptococcus. 

"  It  is  remarkable  that  we  see  or  hear  but  little  of  hypoder- 
matic abscess,  which,  despite  septic  injection,  must  be  an  un- 
common occurrence.  We  can  only  ascribe  this  to  the  fact  that 
in  the  hypodermatic  injection  the  fluid  is  deposited  in  a  com- 
paratively compact  depot  under  the  skin,  and  does  not  come 
intimately  in  contact  with  the  cells  of  the  tissue,  and  thus  per- 
mits of  rapid  phagocytosis,  as  the  blood  is  not  driven  out  of  the 
surrounding  tissue  and  the  fluid  is  rapidly  absorbed.  Quite 
different  is  endermatic  injection,  for  when  fluid  is  slowly  infil- 
trated into  the  tissues  it  distends  the  meshes,  replacing  the 
fluids  and  the  blood  entirely  for  a  length  of  time  (10  to  20 
minutes).  The  infiltrating  fluid  is  brought  intimately  into  rela- 
tion with  the  cellular  elements,  and  phagocytosis  does  not  obtain 
in  time  to  counteract  the  effect  of  implantation  of  septic  germs 
which  could  thus  gain  a  foothold,  and  more  certainly  cause  sup- 
puration than  in  ordinary  hypodermatic  injection. 

' '  A  case  of  sloughing  has  been  brought  to  my  notice  in  which 
the  Schleich  method  was  used  for  anaesthesia  in  operation  for 
mammary  abscess.  The  infiltration  fluid  was  prepared  by  a 
local  druggist  ;  the  infiltration  was  made  by  the  physician  with 
a  hypodermatic  syringe  and  needle  used  for  ordinary  medicinal 
injection.  'Anaesthesia  was  complete,  but  operation  was  fol- 
lowed by  sloughing  of  the  whole  surface  of  the  skin  injected. ' 

"Schleich  does  not  report  any  such  cases  at  his  hands.  In 
several  hundred  injections  that  I  have  made,  I  have  had  no 
trouble.  Reports  coming  to  me  from  other  surgeons  do  not 
chronicle  such  an  event,  which  can  only  be  the  fault  of  the 


NOTES  ON  THE  DANGER  OF  SEPSIS.      407 

operator  Sclileioh  lias  pointed  out  in  his  brochure  and  in  his 
other  writings  that  absolute  sterilization  of  everything  m  connec- 
tion with  the  procedure  should  obtain.  I  have  referred  to  this 
in  my  own  articles.     I  would  emphasize  the  following  points : 

"  I  The  ingredients  of  the  solution  should  be  made  absolutely 
sterile  This  mav  only  be  obtained  by  hoiUng  aU  the  solutions 
for  Jive  minutes  before  each  operation  (afterwards  cooling  the 
same)  The  factor  is  especially  pertinent,  as  leading  manufac- 
turing chemists  in  the  United  States  and  Germany  have  infil- 
tration tablets  on  the  market  for  extemporaneous  preparation 
for  the  several  fluids.  The  tablets  themselves  are  presumably 
aseptic,  but  if  fingered  ever  so  slightly  cannot  remain  pure. 
BoiUng  the  solutiom  after  mixing  does  not  interfere  with  their 

ancpsthetic  qualities.  *  i        i     • 

"II.  The  bottles,  corks  and  stoppers  containing  the  solutions, 
the  dishes  used  in  which  to  pour  out  small  quantities  of  the 
solution,  should  all  be  previously  boiled  (or  sterilized  by  heat), 
and  not  suffered  to  remain  exposed  to  contaminating  influences, 
not  even  the  air,  but  should  be  covered  after  coohng. 

"  It  is  even  more  necessary  for  instruments,  etc.,  to  be  aseptic 
than  for  ordinary  operations.  Any  good  hypodermatic  syringe 
and  needle  may  be  used,  but  should  be  previously  prepared  by 
immersion  for  at  least  one-half  hour  in  a  five  per  cent,  carbolic 
solution,  which  may  be  removed  before  operation  by  washing  in 
sterilized  water.  The  finest  and  sharpest  of  needles  are  advisa- 
ble. These  may  be  sterilized  by  boiling  in  soda  solution  or  by 
carbolic  immersion. 

"The  person  preparing  the  solution  should  prepare  his  hands, 
as  well  as  the  surgeon,  as  carefully  as  if  for  an  abdominal  opera- 
tion. The  part  to  be  operated  upon  should  be  made  aseptic  in 
the  usual  manner.  Attention  to  detail  is  absolutely  necessary 
for  the  success  of  heaUng  as  well  as  for  anaesthesia. 

"It  is  the  fault  of  the  operator  if  he  does  not  secure  perfect 
anaesthesia  and  aseptic  infiltration,  followed  by  good  healing." 

Messrs.  John  Wyeth  &  Brother  have  prepared  from  the 
formulge  of  Dr.  Schleich  a  series  of  soluble  compressed  tablets, 
which  can  be  obtained  from  any  regular  pharmacist. 

«  It  is  a  well  recognized  fact  that  boiling  destroys  the  cocaine,  so  it 
is  to  be  added  when  cool. 


408  ARTIFICIAL    ANESTHESIA. 

The  advantages  of  these  soluble  compressed  tablets  are  mani- 
fold. They  are  at  once  soluble,  are  made  of  the  several  desired 
strengths,  are  permanent  and  stable,  the  solutions  can  be  pre- 
pared in  a  moment,  the  fear  of  septic  infection  from  stale  solu- 
tions is  entirely  removed,  the  operator  can  always  be  supplied 
with  more  than  sufficient  for  any  emergency,  and  the  combined 
ingredients  do  not  deteriorate  or  change  by  age  or  climatic 
influences.  We  feel  there  is  a  wide  field  for  the  use  of  this 
method,  not  only  in  the  hands  of  surgeons,  but  with  the  general 
practitioner,  for  the  relief  of  local  pain,  and  to  the  dentist  they 
will  prove  an  invaluable  aid. 

The  following  are  the  sizes  of  these  soluble  compressed  tab- 
lets: 

Tablets  to  Make  100  Minims  of  Solution. 

No.  1. — Strong. 

Cocaine  hydrochlor., 1-5  grain. 

Morph.  hydrochlor., 1-40  grain. 

Sodium  chloride,  C.  P., 1-5  grain. 

One  tablet  dissolved  in  100  minims  of  water  yields  the  Strong 
Solution,  representing : 

1-500  part  of  cocaine  hydrochlor. 
1-4000  part  of  morph.  hydrochlor. 
1-500  part  of  sodium  chloride, 
or  each  1000  minims  contain 

2  grains  cocaine  hydrochlor. 
1-4  grain  morph.  hydrochlor. 
2  grains  sodium  chloride. 
No.  2. — Normal. 

Cocaine  hydrochlor.,        .         .         .         .         .     1-10  grain. 

Morph.  hydrochlor., 1-40  grain. 

Sodium  chloride,  C.  P., 1-5  grain. 

One  tablet  dissolved  in  100  minims  of  water  yields  the  Normal 
Solution,  representing; 

1-1000  part  of  cocaine  hydrochlor. 
1-4000  part  of  morph.  hydrochlor. 
1-500  part  of  sodium  chloride, 
or,  in  other  words,  each  1000  minims  of  this  Solution  equal : 

1  grain  cocaine  hydrochlor. 
1-4  grain  morph.  hydrochlor. 

2  grains  sodium  chloride. 


NOTES    ON    THE    DANGER    OF    SEPSIS.  409 

No.  3.~Weah 

Cocaine  hydrocblor., 1-100  grain. 

Morph.  hydrocblor., 1-40  grain. 

Sodium  chloride,  C.  P., 1-5  grain. 

One  tablet  dissolved  in  100  minims  of  water  yields  the  Weak  Solu- 
tion, representing: 

1-10,000  part  of  cocaine  hydrocblor. 
1-4000  part  of  morph.  hydrocblor. 
1-500  part  of  sodium  chloride, 
or  each  1000  minims  of  Solution  contain 

1-10  grain  cocaine  hydrocblor. 

1-4  grain  morph.  hydrocblor. 

2  grains  sodium  chloride. 

Should  more  than  100  minims  be  required,  use  one  tablet  for  every 
100  minims  of  water  used. 

Tablets  to  Make  500  Minims  of  Solution. 

No.  4. — Strong. 

Cocaine  hydrocblor., 1  grain. 

Morph.  hydrocblor., 1-8  grain. 

Sodium  chloride,  C.P., 1  grain. 

One  tablet  dissolved  in  500  minims  of  water  yields  the  Strong  Solu- 
tion. 

No.  5. — Normal.     . 

Cocaine  hydrocblor., 1-2  grain. 

Morph.  hydrocblor., 1-8  grain. 

Sodium  chloride,  C.P., 1  grain. 

One  tablet  dissolved  in  500  minims  of  water  yields  the  Normal 
Solution. 

No.  6.— Weak. 

Cocaine  hydrocblor,, 1-20  grain. 

Morph.  hydrocblor.,         .....  1-8  grain. 

Sodium  chloride,  C.P 1  grain. 

One  tablet  dissolved  in  500  minims  of  water  yields  the  Weak  Solu- 
tion. 

Should  more  than  500  minims  of  solution  be  required,  use  one  tab- 
let to  every  500  minims  of  water. 

In  cases  where  the  Solution  is  desired  to  be  stronger  or  weaker 

27 


410  ARTIFICIAL    ANAESTHESIA. 

than  the  Normal  Solution,  but  being  of  the  same  relative  pro- 
portions of  Cocaine,  Morphine  and  Sodium  Chloride  as  in  the 
Normal  Solution,  all  that  is  necessary  is  to  either  increase  or 
decrease  the  quantity  of  water  to  be  used  to  each  tablet  of  the 
Normal  Recipes  No.  2  and  No.  5. 

Special  attention  is  called  to  the  fact  that  in  the  Normal  (No. 
2),  Strong  (No.  1)  and  Weak  (No.  3)  tablets  only  the  Cocaine 
Hydrochlorate  varies,  while  the  Morphine  Hydrochloride  and 
the  Sodium  Chloride  are  the  same  amounts  in  all  three  recipes. 
This  also  applies  to  Nos.  4,  5  and  6. 

The  Tablets  are  put  up  in  tubes  of  20  tablets  each,  in  cases 
holding  10  tubes,  and  also  in  larger  packages,  such  as  lOO's, 
500's  and  lOOO's. 

Dr.  Bransford  Lewis,  of  St.  Louis,  in  an  article  in  the  Med- 
ical Standard*  giving  his  experience  in  the  use  of  this  method, 
cites  the  following  practical  points  : 

"Every  tissue  of  the  body,  without  exception  (skin,  muscle, 
gland,  mucous  membrane,  nerves,  etc.),  becomes  insensible  to 
pain  when  infiltrated  in  the  manner  described.  This  obtains 
for  bone  and  the  hard  structures  as  well  as  the  soft  ones.  Bone 
is  reached  either  through  infiltrating  its  periosteum  or  by  in- 
jecting into  the  medulla.  Nerve  trunks  are  anaesthetized  sepa- 
rately, first  by  applying  5  per  cent,  carbolic  acid  solution,  and 
then  through  this  inserting  the  needle  and  fluid. 

"  Only  the  infiltrated,  artificially  oedematous  tissue  is  anaes- 
thetic, the  tissues  just  outside  retain  normal  acuteness  or  insen- 
sibility. Consequently  in  the  course  of  an  operation,  with 
absorption  of  the  infiltrated  fluid,  it  is  necessary  to  renew  the 
injections  or  extend  their  area  coincidently  with  the  operative 
fluid. 

"With  the  proper  fluid  anaesthesia  ensues  immediately  on 
its  being  introduced  into  the  tissues,  and  lapse  of  time  is  not 
requisite  for  developing  insensibility.  This  again  is  in  marked 
contrast  to  the  efl"ect  of  the  older  methods  of  producing  anaes- 
thesia.    Its  advantage  is  great. 

"Anaemia  resulting  from   the  method,    there  will  be  less 

*  Medical  World,  p.  41,  February,  1896. 


USE  OF  COCAINE  UPON  NASAL  MUCOUS  MEMBRANE.     411 

bleeding  (oozing)  than  under  ordinary  circumstances.  Distor- 
tion of  the  tissue  from  the  infiltrated  fluid  does  not  cause  any 
especially  increased  diflficulty  in  securing  and  tying  or  twisting 
bleeding  vessels.  Nevertheless,  in  operating  in  deeper  struc- 
tures, care  must  be  taken  to  avoid  risk  of  piercing  blood-vessels, 
nerves,  etc. 

"Strong  solution  of  cocaine  (10  to  20  per  cent.)  will  quickly 
constringe  the  vessels  and  hence  will  not  be  absorbed  ;  while  a 
weak  solution  (1  to  5  per  cent.)  will  be  absorbed  and  produce 
S3^stemic  poisoning. ' ' 

The  Use  of  Cocaine  Upon  the  Xasal  Mucous  Mem- 
brane Prior  to  and  During-  Anaesthesia. 

Kosenberg,  in  an  article  published  in  the  Berliner  KUnische 
WocJienschreft,  Nos.  1  and  2,  1895,  advocates  the  use  of  cocaine 
upon  the  nasal  mucous  membrane  prior  to  and  during  anaes- 
thesia, claiming  three-fold  advantages : 

1.  As  the  patient's  perception  of  the  odor  of  the  anaesthetic 
is  much  diminished,  the  feeling  of  suffocation  is  entirely  absent. 

2.  The  stage  of  excitement  is  either  shorter  or  entirely  absent. 

3.  Vomiting  during  narcosis  is  rarer  than  usual. 

4.  Sickness  following  anagsthesia  does  not  occur. 

G-erster  reports  the  results  in  100  cases  where  this  method 
was  employed  in  the  operating  room  of  the  G-erman  Hospital, 
New  York. 

A  5  per  cent,  solution  of  cocaine  was  used.  The  patient  freed 
his  nose  from  mucus,  and  2  minims  of  the  solution  were  sprayed 
into  each  nostril.  Two  minutes  later  the  process  was  repeated, 
one-half  of  the  quantity  being  employed.  Every  half-hour  dur- 
ing the  operation  the  nose  is  again  sprayed  and,  for  the  last 
time,  just  before  the  patient  leaves  the  table. 

In  52  cases  chloroform  was  given  ;  ether  in  24  cases ;  and  the 
A.  C.  E.  mixture  in  13  cases.  In  the  other  cases  more  than 
one  of  these  anaesthetics  were  employed.  It  was  found  that 
the  cocaine  diminished  considerably  the  distress  and  oppres- 
sion felt  by  the  patient  at  the  beginning  of  the  anaesthetic,  and 
that  the  reflex  irritation,  as  manifested  by  struggling,  coughing 
and  nausea,  is  diminished. 


412  ARTIFICIAL    ANESTHESIA. 

In  from  10  to  20  of  the  cases  there  were  sj'mptoms  such  a& 
marked  pallor  and  acceleration  of  the  pulse  rate,  followed  by 
profuse  sweating,  which  were  considered  directly  due  to  cocaine. 
There  was  less  nausea,  vomiting  and  malaise  than  usually  fol- 
lows anaesthesia.  Vomiting  is  recorded  as  following  25  per 
cent,  of  the  cases.  In  alcoholic  cases  Rosenberg's  method 
affords  little  advantage  over  the  usual  anaesthetization.  {Ame?-- 
ican  Medico- Surgical  Bulletin^  February  8,  1896,  p.  192.) 

Another  method  has  been  proposed  by  Dr.  David  H.  Loud- 
Ion,  of  Denver.  A  preliminary  spray  of  the  pharynx  and  naso- 
pharynx with  a  mixture  of  ether  one  part,  and  liquid  petrolatum 
two  parts,  with  a  solution  of  cocaine  if  desired.  ( The  Phila- 
delphia Polyclinic,  February  8,  1896,  p.  55.) 


CHAPTER    XVII. 

On  the  Use  of  Cocaine  in  the  Teeth,  Nose,  Throat  and  Eye. 

Every  now  and  then  there  are  reported  in  the  medical  jour- 
nals the  most  absurd  statements  of  poisoning  by  cocaine.  The 
following  is  an  example,  no  name  nor  journal  given  :  ''  Suffered 
from  toothache,  the  tooth  being  '  dead '  and  the  nerve  canal 
having  been  drilled  out  (acted  as  his  own  dentist),  and  con- 
cluded to  extract,  and  the  tooth  broke.  Injected  the  gums  with 
a  two  per  cent,  solution  of  cocaine.  (Not  stated  if  freshly  made 
or  what  the  cocaine  was  dissolved  in,  alcohol  or  water,  hot  or 
cold.  Or  if  he  had  the  right  kind  of  syringe,  which  should  be 
longer  than  ordinary  hypodermic,  with  handles  so  that  sufl&cient 
control  over  the  force  can  be  made  to  penetrate  down  to  the 
tooth.)  Waited  half  an  hour  and  again  injected  about  the 
same  amount  of  cocaine,  and  still  failed  to  secure  the  offending 
root.  It  still  paining,  concluded  to  inject  the  nerve  canal, 
and  inserted  needle  and  making  considerable  pressure  (irregu- 
lar), when  suddenly  the  plunger  went  home,  and  about  twenty 
drops  (more  or  less)  of  the  solution  passed  into  the  alveolar 


WAS    IT    COCAINE    POISONING?  ,      413 

process.  Instantly  all  pain  ceased.  (Cocaine  is  not  instantane- 
ous in  its  action.) 

"In  thirt}'  minutes,  however,  I  liad  a  decided  rigor,  followed 
by  profuse  sweating  and  vomiting,  cold  extremities  and  a  ter- 
rific headache.  These  symptoms  continued  for  some  forty-eight 
hours.  Not  over  a  drachm  (or  hi  gr.  of  cocaine)  of  the  two  per 
oent.  solution  was  used."  All  of  these  sj^mptoms  might  well 
have  followed  such  a  bungling  operation,  and  not  one  particle  of 
cocaine  need  have  been  employed. 

Here  is  just  such  another  case: 

Was  it  Cocaine  Poisoning? 

On  November  27th  I  was  hastily  called  to  the  ofl&ce  of  our  den- 
tist, and  found  there  a  case  as  follows :  Female,  about  28  years 
old,  married,  and  the  mother  of  three  children,  the  youngest 
about  four  months  old.  She  had  had  three  teeth  extracted 
(the  last  one  broke),  and  for  a  local  anaesthetic  about  forty 
minims  of  the  following  solution  had  been  used : 

^>    Cocaine  hydrochlor., gr.  vj 

Pheuacetiue, gr.  xxiv 

Menthol, gr.  v 

Ether, m.  xxx 

Glycerine, dr.  j 

Water, •  .  oz.  j.     M. 

"  As  the  last  one  was  being  drawn  she  became  unconscious  and 
respiration  ceased.  It  was  on  the  opposite  side  of  the  village 
from  my  office,  and  when  I  got  there  I  found  her  much  in  the 
same  condition  as  above  described,  though  the  heart's  action 
was  good,  considering  the  length  of  time  she  had  been  in  this 
condition.  I  immediately  gave  -^  gr.  strych.  nitrat.  hypoder- 
matically,  followed  with  whiskey,  and  used  artificial  respiration, 
and  in  a  few  seconds  she  began  to  breathe,  and  after  about 
three-fourths  of  an  hour  began  to  try  to  talk.  After  a  short 
time  I  had  her  removed  to  her  home,  but  on  reaching  there 
she  had  relapsed  into  the  same  condition  as  at  first,  and  this 
time  the  pulse  was  so  weak  that  it  was  scarcely  perceptible.  I 
immediately  gave  3^  gr.  strych.  nit.  hypodermatically  and  more 


414      «  ARTIFICIAL    ANESTHESIA. 

whiskey,  and  in  a  few  minutes  she  had  rallied  sufl&ciently,  so  I 
gave  her  aromatic  spirit  of  ammonia  by  the  mouth,  and  in  an- 
other half-hour  she  began  to  call  for  her  baby.  Did  not  let 
baby  nurse  until  next  morning,  and  then  not  until  the  breasts 
had  been  emptied  twice  with  the  breast-pump.  On  the  follow- 
ing day,  i.e.,  on  the  28th,  I  found  her  sitting  up,  but  she  com- 
plained of  feeling  so  very  tired.     She  has  made  a  good  recovery. 

"  Now,  was  it  the  effect  of  the  fluid  used,  or  did  it  come  from 
the  shock  produced  by  breaking  the  last  tooth  ?  I  know  it  was 
not  all  hysterical,  and  besides,  she  has  never  had  hysteria  in  the 
past.  Did  the  fact  that  she  was  a  '  nursing  woman  '  have  any- 
thing to  do  with  the  case?  The  dentist  told  me  he  thought  she 
swallowed  some  of  the  fluid  which  leaked  out  of  the  syringe  and 
fell  into  her  mouth,  and  that  the  gums  did  not  bleed  very  much. 

"  I  have  used  cocaine  (four  per  cent,  solution),  being  careful  to 
not  exceed  ten  minims  at  a  time,  since  I  have  been  practicing 
medicine,  and  have  used  it  regardless  of  the  color  of  the  hair 
and  eyes,  and  have  never  had  any  bad  results  from  it."* 

In  both  of  these  cases  there  were  large  doses  employed,  and 
the  cocaine  also  swallowed.  The  hysterical  element  had  also  an 
important  influence  in  these  so-called  cases  of  cocaine  poisoning. 
It  is  well  known  to  all  surgeons  of  any  long  experience  that  the 
most  simple  operation  in  minor  surgery  will  be  followed  by  syn- 
cope, difficulty  of  breathing,  fainting  and  prostration,  and  indeed 
all  the  symptoms  described  as  poisoning,  as  in  the  above  case,  all 
of  which  can  be  promptly  relieved  with  aromatic  spirits  of  am- 
monia and  whiskey. 

Cocaine  is  not  necessarily  a  dangerous  anassthetic  if  carefully 
prepared  with  distilled,  sterilized  water,  and  used  in  an  absolutely 
clean  hypodermic  syringe,  for  in  the  last  six  years  there  has  not 
been  one  death  due  to  its  use,  in  the  city  of  Philadelphia.  If 
it  is  to  be  kept  a  short  time,  add  a  small  amount  of  phenol, 
say  five  per  cent.  If  the  patient  is  feeble,  add  a  minute  quan- 
tity of  morphia  and  atropia,  150th  of  a  grain,  as  it  sustains  the 
heart  action ;  careful  compression  by  the  fingers  each  side  of 
the  tooth,  by  an  assistant,  in  extraction. 

*  C.  H.  Herrick,  M.D.,  Gilbertsville,  N.  Y.,  Medical  World,  Jan- 
uary, 1896. 


USE    OF    COCAINE    IN    THE    NOSE    AND    THROAT.        415 

The  Use  of  Cocaine  in  the  Nose  and  Throat. 

There  are  certainly  but  few  individuals  who  are  so  susceptible  to 
the  influence  of  cocaine,  that  it  cannot  be  carefull}^  applied  to  the 
nose  or  throat  by  means  of  a  pledget  of  absorbent  cotton  charged 
and  applied  to  the  part  to  be  operated  upon.    By  this  we  are  able 
to  determine  whether  the  apparent  hypertrophy  of  the  tissues 
is  real  or  only  temporary.     We  very  rarely  spray  the  part,  but 
apply  solutions  varying  from   four  to  ten   per  cent.     If  it  is 
simply  to  diminish  secretions,  we  use  the  four  per  cent.  ;  but 
when  a  polypus,  tonsil,  or  part  of  the  turbinated  bone  is  to  be 
removed,  we  increase  the  solution  to  ten  per  cent.     In  this 
manner  we  can  apply,  without  pain,  a  small  ball  of  chromic 
acid,  chloroacetic  acid,  or  crystals  of  nitrate  of  silver.     After 
the  production  of  local  anaesthesia,  with  shrinking  of  the  erec- 
tile tissue,  in  the  course  of  a  shorter  or  longer  period  there 
occurs  a  decided  reaction,  and   the  blood  returns  with  great 
force.     To  prevent  this  we  spray  the  part  with  an  alkaline  solu- 
tion, and  then  with  a  four  per  cent,   solution  of  antipyrin.     If 
there  is  acute  or  chronic  rhinitis,  it  is  treated  by  spraying  the 
nasal  fossae  every  other  day  with  liquid  vaseline  or  alboline,  in 
which  are  dissolved  in  each  ounce  five  grains  of  menthol  with 
two  of  extract  of  eucalyptus.     This  local  treatment  with  cocaine 
we  have  kept  up  for  the  last  six  years  with  satisfaction,  and 
with  the  exception  of  once  in  a  while  as  in  the  case  of  an  hysteri- 
cal woman,  who,  after  the  application  of  a  solution  of  cocaine  to 
her  nasal  mucous  membrane,  will  suddenly  feel  faint,  with  di- 
lated pupils,  extremities  cold,  and  heart  action  rapid  and  feeble ; 
but  this  is  soon  relieved  by  placing  her  flat  on  the  ground,  and 
applying  a  few  whiff's  of  ether  with  ammonia  to  the  nostrils, 
and  administering  from  thirty  to  sixty  drops  of  aromatic  spirits 
of  ammonia  internally  with  water. 

Cocaine  in  Diseases  of  the  Ear. — In  our  third  edition,  on 
pages  86  to  90,  will  be  not^d  that  we  have  used  cocaine  very 
freely  in  diseases  of  the  ear,  and  found  it  of  great  value  in  re- 
lieving pain  within  the  middle  ear  when  removing  diseased 
structure,  bone  tissue,  and  especially  in  ulcerations,  in  which  we 
use  the  curette  with  the  application  of  powerful  agents  to  the 
parts  with  the  same  precaution  as  in  the  throat  or  nose.     We 


416  ARTIFICIAL    ANAESTHESIA. 

now  but  seldom  use  the  general  annestlietic  except  in  deep-seated 
operations,  when  the  ossicles  are  remov^ed,  or  diseased  mastoid, 
or  large  masses  of  dead  bone.  In  every  instance  in  which  we 
use  cocaine  to  the  ear,  especially  when  the  drum-membrane  is 
removed,  we  apply  it  by  absorbent  cotton  to  the  part  to  be 
treated,  and  always  after  five  minutes  follow  it  by  the  four  per 
cent,  of  antipyrin  sprayed  over  the  part. 

When  we  employ  it  in  the  Eustachian  tube  or  in  the  pharynx, 
in  its  vicinity  we  tip  the  Eustachian  forceps  or  delicate  appli- 
cator with  absorbent  cotton,  and  then  charge  it  with  cocaine 
solution,  avoiding  all  excess  which  may  pass  into  the  interior. 
Even  when  it  passes  into  the  oesophagus,  we  maj'  find  a  small 
portion  produce  only  dryness  with  a  loss  of  taste  for  a  few  hours. 

Cocaine  in  Diseases  of  the  Eye. — The  proper  method  of 
preventing  any  injurious  influence  upon  the  eye  is,  in  all  cases 
of  operation,  to  use  the  solution  of  two  to  four  per  cent.,  which 
should  be  made  fresh  each  time  it  is  required.  The  packing  of 
the  hypodermic  syringe  is  also  to  be  cleansed  by  passing  through 
the  same  antiseptic  solution,  as  it  is  apt  to  become  foul.  When 
it  is  given  to  a  patient  as  an  ordinary  eye-wash,  a  solution  of 
boric  acid  is  made  with  a  minute  portion  of  cocaine  added,  and 
this  solution  is  to  be  employed  with  a  dropper  kept  in  an  air- 
tight bottle  and  case.  The  dropper  is  to  be  carefully  washed 
out  with  a  hot  antiseptic  solution  of  bicarbonate  of  sodium  in 
boiling  water  after  using  it. 

Deaths  from  Cocaine. 

In  a  recent  article"^  by  a  medical  gentleman  of  experience  in 
the  use  of  this  valuable  anaesthetic,  cocaine,  he  stated  there 
had  been  a  very  large  number  of  deaths  from  this  agent. 

Fearing  that  I  might  not  have  an  account  of  all  the  deaths, 
I  wrote  to  him,  desiring  him  to  be  so  good  as  to  give  me  a  list 
from  the  numerous  researches  he  had  made,  of.  any  cases  of 
death  since  my  enumeration  up  to  1890.  The  following  was  his 
kind  reply : 

*•  Med.  and  Surg.  Eeporter,  February  15,  1896. 


DEATHS    FROM    COCAINE.  417 

"  FEBRirARY  20,  1896. 
''^  My  Dear  Doctor  : 

"The  following  cases  of  death,  due  to  the  injection  of  co- 
caine, have  come  to  notice  since  1890.  There  have  been,  of 
course,  many  more  during  the  past  five  years,  but  one  finds,  on 
looking  up  the  literature  of  the  subject,  that  many  writers  have 
reported  numbers  of  cases  at  a  time,  and  do  not  specify  the 
dates,  so  I  cannot  state  how  many  cases  occurred  before  and 
since  1890. 

"The  Lyons  Medical,  Lyons,  published  in  August,  1891,  a 
report  of  a  death  in  a  dentist's  ofiice. 

"  Delbose  reported  five  deaths  in  the  Journal  de  Medicine  et 
de  Chirurgie,  of  Paris,  February,  1891. 

"In  1892  and  '93  Dufournier  reported  nine  deaths  in  the 
Archives  G-enerales  de  Medicine." 

This  we  found  to  be  a  mistake,  as  his  last  case  was  Septem- 
ber, 1888,  and  published  in  October,  1889. 

In  my  third  edition  (p.  49-55),  1890,  there  was  reported  every 
case  of  death  from  cocaine  in  full  up  to  December,  1889  ;  in  all, 
eight  cases,  when  we  went  to  press,  from  the  time  of  its  intro- 
duction in  1855.  Most  of  the  cases  of  death  were  obtained 
from  a  monograph  by  Dr.  Mattison,  of  New  York,  and  my  own 
examination  of  every  journal  published,  both  of  this  country 
and  of  Europe.  The  following  were  my  conclusions  after  a  care- 
ful study  of  every  case  reported.  There  has  been  as  far  as  I  am 
informed  but  one  death  reported  as  having  occurred  in  this  city^ 

In  a  careful  reading  of  Dr.  Mattison's  before-referred- to  mon- 
ograph we  found  a  few  points  on  which  we  wanted  a  little  more 
definite  information,  and  wrote  to  him  for  that  purpose,  but  re- 
ceived no  reply.  The  name  of  the  journal  in  which  were  given 
the  details  of  the  Russian  surgeon's  case  is  not  reported.  Might 
not  the  operation  of  scraping  and  cauterizing  a  tuberculous 
ulcer  have  caused  the  death  of  the  young  woman  ?  Was  not 
three-quarters  of  an  hour  a  long  time  before  the  cocaine  had 
developed  its  toxic  efi'ects?  We  find,  as  a  rule,  they  are  decided 
in  five  to  eight  minutes.  We  cannot  find  the  number  of  the 
American  Lancet  in  which  the  case  is  reported  by  Dr.  Long. 
What  was  the  disease  of  the  larynx  ?     The  case  of  Dr.  F.  M. 


418  ARTIFICIAL    ANAESTHESIA. 

Thomas  was  not  reported  in  any  medical  journal.  Judging 
from  the  symptoms,  the  woman  died  from  paralysis,  and  had 
been  under  treatment  for  the  same.  We  were  unable  to  find 
where  Dr.  Knabe's  case  was  published.  Such  cases  frequently 
die  from  cardiac  degeneration  followed  by  dropsy,  the  result 
of  scarlatina  ;  the  dose  was  so  small,  only  four  to  twelve  drops 
— the  exact  amount  not  determined — of  a  four  per  cent,  solu- 
tion. Now  we  come  to  the  case  of  Dr.  Simes,  of  Philadelphia. 
In  reading  this  case  over  carefully  we  are  of  the  opinion,  from 
the  symptoms  and  post-mortem  record,  that  the  man  had  been 
an  epileptic;  and  again  a  twenty  per  cent,  solution  is  too  strong, 
and  should  never  be  employed  in  the  urethra  or  rectum,* 
as  it  enters  the  veins  by  endosmosis,  and  it  also  acts  upon 
the  spinal  nerve,  and  has  been  found  a  true  cerebro-spinal  ex- 
citant in  large  doses.  The  dose  internally  is  one-sixth,  one- 
fourth,  one-third  of  a  grain.  We  find  that  with  a  two  per  cent, 
solution,  with  acid  carbolic  gr.  x.  to  the  oz.,  we  obtain  all  the 
results  we  desire  if  repeated,  and  if  possible  controlled  by  posi- 
tion, or  a  ligature,  as  suggested  by  Corning,  of  a  rubber  tube. 

The  case  reported  by  Abadie  is  very  imperfect  in  its  details 
and  cannot  be  received  until  further  information  is  obtained, 
still  we  consider  it  our  duty  to  publish  all  the  cases  of  alleged 
deaths,  so  as  to  induce  a  proper  caution  in  persons  who  have 
never  employed  the  drug,  just  as  we  do  in  prescribing  morphia 
and  other  powerful  alkaloids. 

In  the  two  cases  reported  by  "Lanianchi  and  Montalli  "  the 
first  was  an  epileptic  and  the  second  one  afflicted  with  phthisis. 
In  one  case  Montalli  gave  in  mistake  twenty-two  grains  of  the 
drug. 

Reclus  reported  to  the  Societe  de  Chirurgie,  21  Mars,  a  case 
of  death  from  cocaine.  It  occurred  in  the  hands  of  another 
doctor.  The  patient  was  a  man,  aged  72  years,  affected  with 
enlarged  prostate  and  retention  of  urine.  Aspiration  was  per- 
formed, and  the  next  day,  it  having  been  found  again  impossi- 
ble to  enter  the  bladder  through  the  urethra,  he  injected  twenty 

*  Six  grains  has  produced  poisonous  symptoms  when  employed,  in 
the  rectum. 


DEATHS    FROM    COCAINE.  419 

cubic  centimetres  of  a  five  per  cent,  solution  of  cocaine.  The  man 
was  at  once  seized  with  tremors,  became  pale,  and  succumbed  in 
a  few  minutes.  Reclus  states  that,  as  a  general  rule,  a  two  per 
cent,  solution  only  should  be  injected,  and  not  more  than  fifteen 
to  twenty  centigrammes  of  it  at  a  time.  If  these  two  rules  had 
been  observed  the  accident  would  not  have  taken  place. — La 
Tribune  Medlcale,  March  29,  1894. 

Being  desirous  of  obtaining  the  record  of  deaths  from  cocaine 
and  verifying  those  cases  of  deaths  which  I  had  obtained  up  to 
the  time  of  my  edition  of  1890,  I  wrote  to  my  friend,  Dr.  Marcel 
Natier,  of  Paris,  who  most  kindly  sent  me  the  Arch.  General  de 
Medicine,  October,  1889,  which  I  found  contained  three  extra 
cases,  making  in  all  eleven  deaths,  which  were  as  follows  : 

Case  9. 

An  interne  of  the  University  College  Hospital  had  ordered 
1  gram.  25  cent.  gram,  of  cocaine  with  the  intention  of  injecting 
it  into  the  bladder  of  a  man,  30  years  of  age,  troubled  with  acute 
cystitis.  Unfortunately  he  had  neglected  to  state  the  use  of 
the  drug  on  his  prescription  and  the  druggist  delivered  it,  telling 
the  nurse  it  was  probably  a  potion.  It  was  given  as  such,  and 
the  patient  succumbed. 

It  was  not  at  first  pronounced  an  accident,  but  at  the  end  of 
a  half-hour  convulsions  set  in,  and  from  those  he  died. — Bull. 
Med.,  24Fevrier,  1889. 

This  was  a  case  of  direct  poisoning  by  the  use  of  over  15 
grains,  and  no  means  employed  to  prevent  its  fatal  effects. 

Case  10. 

A  woman  swallowed  by  mistake  5  grammes  of  a  solution  of 
chlorohydrate  of  cocaine,  30  per  cent. 

A  quarter  of  an  hour  after  the  ingestion  the  patient  was 
taken  with  a  spasm  of  the  throat,  nauseated  without  vomiting. 
The  lips  became  cyanosed,  the  pupils  dilated,  the  pulse  almost 
imperceptible,  and  the  patient  succumbed  amidst  convulsions. 

At  the  post-mortem  a  small  cavity  was  found  in  the  right 
lung,  with  a  slight  fatty  degeneration  of  the  heart.     The  brain, 


420  ARTIFICIAL    ANAESTHESIA. 

the  meninges  and  the  abdominal  viscera  were  congested.  (Mon- 
talli,  Lo  Sperimentate^  Sept.,  1888.) 

A  more  recent  case  of  recovery  was  reported  by  Dr.  M.  V. 
Ball,  of  Philadelphia,  where  a  patient  of  his,  with  a  suicidal 
intent,  swallowed  a  solution  of  cocaine  (6  drachms),  of  a  five 
per  cent,  solution  of  cocaine,  equal  to  about  1 82"  grains.  Reco- 
very took  place  under  the  use  of  black  coffee ;  strychnine, 
^V  grain,  was  administered  by  the  mouth,  and  some  champagne 
was  given.  The  early  administration  of  ^  of  a  grain  of  morphia 
did  probably  influence  the  course  of  the  case. 

I  am  also  indebted  to  Dr.  Natier'^  for  the  following  death 
which  have  occurred  since  1890,  only  three  cases  in  six  years,  and 
which  confirm  my  observations  that  in  the  proper  selected  cases 
and  the  exact  dose,  not  to  exceed  J  grain,  it  will  be  found  the 
most  valuable  local  anaesthetic  that  we  can  employ,  especially 
when  associated  with  small  quantities  of  morphia  and  chloride 
of  sodium  in  solution. 

Dr.  Bergu  relates  the  history  of  a  man  who,  in  October, 
1891,  was  operated  upon  at  the  Hospital  Lariboisiere  for  a  sim- 
ple hydrocele,  of  medium  size,  of  two  months'  duration.  He 
used  an  injection  of  iodine  after  anaesthesia  of  the  vaginal 
tunic,  by  means  of  a  soupspoonful  (probably  a  tablespoon — 
about  250  M. — 5  grains)  of  solution  of  hydrochlorate  of  cocaine, 
fifty  per  cent.  After  twenty  minutes'  rest,  the  patient  left  the 
hall,  but  returned  ten  minutes  later,  feeling  indisposed ;  went 
into  a  state  of  syncope,  followed  by  convulsions  and  pupillary 
phenomena. 

Injections  of  ether,  artificial  respiration,  tracheotomy,  inha- 
lations of  oxygen,  all  were  useless,  and  death  followed  rapidly. 
The  well-known  and  usual  clinical  and  experimental  symptoms 
of  cocaine  poisoning  were  well  manifested.  The  autopsy  made 
by  Dr.  M.  Richardson  (who  had  already  reported  medico-legally 
11  cases  of  death  from  cocaine,  all  that  he  could  collect  since 
its  introduction)  revealed  no  mortal  lesion.     There  was   only 

*  Dr.  Marcel  Natter,  Chef  du  Service  des  Maladies  dii  Nez,  des 
Oreilles  et  da  Larynx  a  la  Polyclinique  de  Paris;  Editor  Eevue  Inter- 
national, Rhinologie,  Otologic  and  Laryngologie. 


COCAINE    IN    GASTRITIS.  421 

congestion  of  the  brain  and  lungs.  There  was  a  slight  mitral 
insufficiency  in  the  heart,  which,  perhaps,  favored  the  acci- 
dent, but  could  not  have  had  an  important  effect.  The  dose 
of  cocaine,  however,  was  not  extraordinarj'— usually  one  puts 
in  the  tunica  vaginalis  o.  g.  So.  of  cocaine  for  30  grammes  of 
water.  Perhaps  the  thin  coating  of  this  acute  hydrocele  ab- 
sorbed the  drug  with  unusual  rapidity.  In  any  case,  M.  Bergu, 
who,  after  numerous  operations,  would  have  affirmed,  some 
weeks  ago,  the  absolute  harmlessness  of  this  procedure,  de- 
clares, without  denouncing  cocaine,  that  at  his  next  hydrocele 
he  will  hesitate. 

M.  Eeclus  believes  that  the  maximum  dose  employed  by 
Hcenel  is  dangerous  ;  that  even  0  gr.  0.3  cent.— which  was  the 
quantity  used  with  M.  Bergu' s  patient— is  also  dangerous.  In 
Dr.  Keclus'  first  experiments  he  uses  the  doses  of  0.3  cent.,* 
and  has  had  now  and  then  serious  enough  accidents.  He  does 
not  exceed  0  gr.  20  cent.,  and  he  usually  injects  into  the  hydro- 
cele—not  evacuated— a  0  gr.,  .05  cent.,  on  0  gr.,  .075  cent.,  a 
syringeful,  and  has  never  had  the  slightest  alarming  symptoms, 
while  angesthesia  has  been  very  well  produced.  To  exceed  this 
dose  is  both  useless  and  dangerous.  It  is  absolutely  necessary 
to  recognize  the  possibility  of  danger  from  rapid  absorption 
through  the  thin  coating  of  an  acute  hydrocele. 

*  The  French  use  the  abbreviation  gr.  to  signify  gramme  and  c.  for 
centigramme. 


422  ARTIFICIAL    ANESTHESIA. 


CHAPTER  XVIII. 

Therapeutics  of  Cocaine — Gastritis  produced  by  Poisoning  treated  by 
Cocaine,  and  Aflfections  of  the  Stomach,  Tetanus.  Skin  Disease. 

Cocaine  in  Gastritis  Produced  by  Poisoning-. 

In  a  recent  case  published  by  a  physician*  in  Scranton,  Pa., 
a  young  girl,  after  an  unsuccessful  attempt  at  suicide  by  lauda- 
num, took  "Rough  on  Rats."  She  was  given  ipecac  and 
sulphate  of  zinc  ;  also  large  quantities  of  dialized  iron  and  lime- 
water.  Two  grains  of  morphine  were  administered  hypoder- 
matically  in  divided  doses  during  the  night,  and  the  woman  was 
kept  anaesthetized  by  means  of  chloroform  and  ether  for  twelve 
hours.  Whenever  the  anaesthetic  was  withdrawn,  the  patient 
would  rebel,  and  was  with  diflBculty  held  by  three  persons  when 
not  profoundly  under  the  influence  of  ether.  Twelve  hours 
after  the  poison  had  been  taken,  the  girl  was  still  in  terrible 
agony,  and  showed  signs  of  collapse.  It  was  suggested  by  an- 
other physician  that  over  half  an  ounce  of  a  four  per  cent, 
solution  of  cocaine  hydrochlorate  (about  ten  grains)  should  be 
administered,  it  being  supposed  that  all  the  arsenic  had  been 
vomited  or  neutralized,  and  that  gastritis  had  set  in.  In  a  few 
minutes  the  patient  ceased  to  complain  of  her  stomach,  the 
mania  subsided  and  the  anaesthesia  was  discontinued.  The 
pulse  grew  stronger,  and  the  woman  was  soon  able  to  walk 
with  assistance. 

Cocaine  in  Affections  of  tlie  Stomacli. 

Cocaine  has  been  found  most  useful  in  certain  affections  of 
the  stomach.  From  the  researches  and  clinical  observations  we 
arrive  at  the  following  conclusions  :  1.  That  cocaine  exerts  on 

*  Dr.  J.  Emmet  O'Brien. 


COCAINE    IN    BOULIMIE    OR    INSATIABLE    HUNGER.       423 

the  mucous  membrane  of  the  stomach,  and  that  of  the  diges- 
tive tube,  an  action  as  certain  as  on  the  external  mucous  mem- 
branes. 2.  That  for  this  action  to  be  as  complete  as  possible, 
one  must  facilitate  the  impregnation  of  the  gastric  and  intesti- 
nal mucous  membranes  by  promoting  their  secretions.  Hence 
the  advantage  of  associating  cocaine  with  alkalies.*  For  the 
action  to  attain  its  maximum  duration,  one  must  add  to  this 
mixture  very  small  doses  of  morphine. 

Cocaine  in  Persistent  or  Uncontrollable  Vomiting. 

From  the  peculiar  action  of  cocaine  upon  mucous  membranes 
and  vascular  tissue,  it  was  supposed,  theoretically,  to  be  capable 
of  diminishing  the  sickness  of  pregnancy  and  other  severe  irri- 
tation of  the  stomach  of  a  reflex  character.  It  has  been  tested 
in  a  number  of  cases  with  more  or  less  success. 


Cocaine  in  Lavage  or  Gavage. 

In  the  act  of  inserting  the  stomach  pump  or  tube  there  is 
almost  always  pain  and  spasm,  due  to  the  contractions  which 
take  place  on  the  isthmus  of  the  fauces,  which  may  be  obviated 
by  painting  with  a  two  per  cent,  solution  of  cocaine.  It  has 
been  found  very  valuable  in  certain  spasmodic  and  even  per- 
manent stricture  of  the  oesophagus;  where  dilatation  is  re- 
quired, a  two  per  cent,  ointment  is  applied  to  the  tube. 


Cocaine  in  Boiiliinie  or  Insatiable  Hunger. 

This  peculiar  intense  and  insatiable  hunger  or  canine  appe- 
tite is  peculiar  to  pregnancy,  and  can  in  some  cases  be  relieved 
by  small  doses  of  hydrochlorate  of  cocaine,  ^  to  t^^  or  even  k 
of  a  grain  taken  at  intervals,  in  pill  form,  while  in  the  recum- 
bent posture. 

*  It  must  be  remembered  tbat  caustic  alkalies  decompose  the 
cocaine. 


424  ARTIFICIAL    ANESTHESIA. 

Tetanus  Treated  by  Morphia  and  Cocaine. 

Lopez  is  quoted  by  the  Journal  of  Nervous  and  Mental  Dis- 
eases, for  December,  1887  (Medical  News,  January  28,  1888),  as 
reporting  in  an  Italian  journal  the  following  case  :  M.  Gr.,  fifty 
years  old,  having  worked  in  the  cold  and  wet,  complained  of 
rheumatic  pains  in  the  back  and  extremities.  Three  days  after 
he  had  an  attack  of  opisthotonus,  painful  spasms  and  all  the 
symptoms  of  idiopathic  tetanus.  Morphine  and  chloral  hy- 
drate were  prescribed.  For  three  days  the  patient,  under  the 
influence  of  these  medicines,  had  little  pain  ;  but  there  was  in- 
creased muscular  rigidity  and  spasms.  At  last  he  was  unable 
to  swallow,  and  death  was  believed  imminent.  Injections  of 
morphine  were  without  efi"ect.  Then  the  writer  injected  three 
syringefuls  of  a  mixture  of  morphia  and  cocaine,  five  per  cent, 
of  each.  The  eff'ect  was  immediate.  After  two  hours  he  could 
move  the  extremities,  open  his  mouth  and  turn  himself  in  bed. 
The  next  day  he  continued  to  improve.  There  remained  a 
slight  trismus  and  a  little  rigidity  of  the  neck.  A  quarter  of  a 
syringeful  of  the  same  solution  was  injected  in  each  side  of  the 
neck,  and  the  day  after  all  the  symptoms  had  disappeared. 

Cocaine  in  Skin  Diseases. 

Lustgarten  (  Wiener  Med.  Wochenschrift,  November  12,  1887) 
states,  what  we  demonstrated  soon  after  cocaine  was  discovered, 
that  where  the  epidermis  is  in  contact,  cocaine  ajiplied  to  the 
skin  is  not  absorbed  ;  but  where  the  horny  layer  is  thin  or  absent 
(removed  by  alkalies,  alcohol  or  chloroform),  it  acts.  A  two 
per  cent,  solution  used  several  times  daily  allays  the  itching  in 
acute  and  subacute  eczema,  being  especially  valuable  in  eczema 
of  the  anus  and  genital  regions  of  both  sexes.  In  the  form  of 
ointment  he  employs  oleate  of  cocaine,  from  6  to  15  grains; 
lanolin,  4 J  drachms;  followed  by  the  use  of  a  dusting  powder 
(two  of  the  best  are  finely-powdered  talc  or  lycopodium).  In 
pruritus  ani,  suppositories  may  be  made  containing  three- 
fourths  of  a  grain  of  oleate  of  cocaine.  The  author  cautions 
against  the  toxic  effects  of  cocaine,  three  cases  of  this  kind 
having  been  encountered  when  only  three-fourths  of  a  grain 
had  been  used. 


COCAINE    IN    CRACKED    NIPPLES.  426 

Treatment  of  Chilblain. 

Apply  with  cotton  or  wool  a  four  per  cent,  solution  of  co- 
caine for  ten  minutes ;  then  remove  the  cotton  and  cover  the 
parts  with  compound  tincture  of  benzoin.  This  repeated  a 
few  times  will  entirely  relieve  the  pain  and  irritation.  A 
valuable  ointment  for  the  same  disease  is  equal  parts  of  oil  of 
turpentine  and  compound  rosin  ointment.  Apply  by  rubbing 
in  the  ointment  near  a  hot  fire  at  bedtime.  Another  salve  is 
recommended  by  Dr.  Lassar  : 

^^    Acid  carbolic  cry  St.,        .....  gr,  xv. 

Ung,  plumbi, 5v. 

Lanolin, 5iiss, 

Oil  amygdal., 


Oil  lavend. 


aa  .        .        .    gr.  xx.    M. 


Cocaine  in  Intense  Itching-  of  the  Skin. 

In  the  various  forms  of  pruriginous  affections  of  the  skin, 
cocaine  with  vaseline  or  a  two  per  cent,  solution  in  alcohol 
will  allay  the  distressing  itching  of  the  skin. 

Cocaine  in  Biu*ns. 

Either  the  solution,  or  ointment  of  cocaine,  has  the  great 
advaritage  of  dissipating  the  intense  pain  of  severe  burns  when 
in  a  two  per  cent,  solution. 

Cocaine  in  Anal  or  Vulval  Priu'iency  or  Painful 

Herpes. 

^    Cocaine  oleat.,  .         .    40  to  i  gramme  (gr.  viiss.  to  xvss.). 
Lanolin,     .        ,         .     18  grammes  (3v.). 
01.  oliv.,     .        ,        .2  grammes  (gr.  xxxi.). 
To  be  used  several  times  a  day. 

— Gaz.  Hebe,  des  Sci.  Mede.,  Montpelier,  Jani  14,  1888. 

Cocaine  in  Cracked  Xipples. 

A  two  per  cent,  powder  of  hydrochlorate  of  cocaine  and 
starch,  applied  to  the  fissure  in  the  nipple  of  nursing  women, 

28 


426  ARTIFICIAL    ANESTHESIA. 

covered  with  collodion,  will  relieve  the  distressing  pain.  The 
same  good  results  follow  fissures  of  the  skin  of  the  hands  during 
very  cold  weather.  A  few  inveterate  cases  require  first  to  touch 
the  fissures  with  a  fine  pencil  of  nitrate  of  silver  very  gently. 

Cocaiue  in  Acute  Catarrh,  Coryza,  or  Cold  in  the 

Head. 

In  acute  catarrh,  or  cold  in  the  head,  we  have  a  condition  of 
engorgement  of  the  blood-vessels  in  the  nasal  mucous  mem- 
brane, and  the  secretion,  which  at  first  is  thin  and  water}^ 
through  hyperstimulation  of  the  glands,  soon  becomes  more 
charged  with  broken-down  epithelial  cells,  lymph  corpuscles, 
pus  globules,  etc.,  until  it  assumes  the  character  of  thick,  tena- 
cious mucus,  or  muco-pus.  If  cocaine  be  applied  early  to  the 
membrane  in  a  case  of  acute  coryza,  its  constringing  influence 
on  the  membrane  must  diminish  the  blood  supply,  and  thus 
prevent  the  engorgement  and  transudation.  We  have  person- 
ally tested  its  abortive  action  in  an  attack  of  coryza. 

As  soon  as  the  initial  stage  has  passed  over,  and  secretion 
commenced,  a  four  per  cent,  solution  should  be  applied  freely 
over  the  interior  turbinated  bones  of  each  side. 

As  is  well  known,  the  coryza  of  nursing  infants  and  young 
children  may,  by  preventing  suckling,  prove  a  very  serious 
afl*ection.  It  can  be  cured,  however,  by  the  introduction  into 
the  nasal  cavity,  six  times  daily,  of  a  one  per  cent,  solution  of 
the  hydrochlorate  of  cocaine,  on  cotton,  for  five  minutes.  Ac- 
cording to  the  author,  children  who  previously  had  obstinately 
refused  to  nurse  will  commence  to  suckle  a  few  minutes  after 
the  first  application  of  the  cocaine,  and  the  coryza  is  ordinarily 
cured  after  about  four  days  of  this  treatment.^ 

^t     Hydrochlorate  of  cocaine,  .         .         .      i  gr. 

Very  finely  powdered  starch,  .         .         .49  grs. 
Mix  intimately. 
SiG. — Use  at  intervals  of  about  an  hour  until  relieved. 

*'  This  treatment  is  made  more  successful  by  the  spray  of  the  anti- 
septic tablets  of  Dr.  Seller ;  also  useful  in  hay  fever  to  cleanse  the 
parts. 


COCAINE    IN    WHOOPING-COUGH.  427 

Cocaine  in  Hay  Fever. 

Sir  Andrew  Clark  prefers  to  use  a  solution  of  five  per  cent., 
applj^ing  it  to  the  interior  of  the  nose  and  back  of  the  soft 
palate,  by  means  of  a  large  camel's-hair  pencil  attached  to  an 
aluminium  shank,  and  bent  at  an  appropriate  angle.  For  use 
in  the  form  of  nasal  bougies  a  quarter  of  a  grain  or  more  of  the 
hydrochlorate  of  cocaine  is  dissolved  in  a  mixture  of  gelatine 
and  glycerine,  and  made  of  different  weights  and  shapes, 
according  to  the  peculiarities  of  the  case  on  which  they  are  to 
be  employed. 

Cocaine  and  Phosphate  of  Lime  in  LarjTigeal 
Tuberculosis. 

Professor  John  Schnetzler  used  phosphoric  acid  in  different 
degrees  of  concentration,  even  in  full  strength,  applied  by 
means  of  a  brush  or  the  S3Tinge  to  the  larynx,  producing  pain 
in  some  cases,  which  he  obviates  by  the  use  of  the  following 
powder : 

^     Cocaine  mur., 0.1  (gram.). 

Calci.  phosphor., 100 

01.  menth.  pip.,     .         .         .         .         .  gtt.  v.  M. 

Use  by  insufflations. 

Though  the  remedy  has  no  specific  influence  on  the  tubercular 
process,  relief  (and  under  favorable  conditions  also  recovery) 
has  been  obtained  in  several  cases  ;  it  is  also  an  excellent  rem- 
edy in  all  catarrhal  affections  of  the  upper  air  passages. — Jour. 
Am.  Med.  Association,  January  21,  1888. 

Cocaine  in  Whooping- Coug-h. 

Dr.  Weintraub,  of  Eydknhuen,  prescribes  the  following 
formula,  with  good  results  : 

^     Cocaine  muriat.,    .        ,        .        .    gr.  j.  ^  to  1  gr. 

Aqu.-amygd.  amar.,      .        .        .     5iiss.  M. 

Si«. — Ten  to  fifteen  drops  several  times  a  day. 

—Alg.  Med.  Central  Ztg.,  91,  1887. 


428  ARTIFICIAL    ANESTHESIA. 

Cocaine  and  Resorcin  in  Wliooping--Cough. 

Resorcin  has  been  found  one  of  the  most  available  remedies 
in  pertussis,  reUeving  the  bacterial  origin  of  the  disease. 
Since  1885  cocaine  has  been  used  as  a  preliminary  to  the  resor- 
cin, as  we  found  that  it  lessened  the  intensity  and  frequency  of 
the  cough  before  the  resorcin  had  time  to  destroy  the  morbific 
germs.  We  use  a  four  per  cent,  solution  and  an  eight  per  cent, 
solution  of  resorcin  ;  and  this  combination  constitutes  the  best 
treatment  for  whooping-cough  now  at  our  command. 

Cocaine  Mixtiu*e  for  Relief  of  Coug^h  and  of  Chronic 

PliarjTigitis. 

The  following  formula  has  been  recommended  for  the  relief 
of  the  cough  in  chronic  pharyngitis : 

^     Cocaine, gr.  iss. 

Glycerine, fSj. 

Aquse  dest., f  3x  5ij. 

Acid  carbol., gr.  i- 

SiG. — Apply  morning  and  evening  with  a  suitable  brush. 

— Medical  News,  April  11,  1885 . 


^ 


^ 


Cocaine  by  Insitfflation  and  Inhalation. 

A.     Inhalation. 

'     Cocaine  hydrochlor.,     . 

•     gr.  iij. 

Potassii  chlorat.,   .... 

.     5ij. 

Aquse  laurocerasi, 

.     fSxij. 

B.     Insuffiation. 

*     Cocaine  hydrochlorat,  . 

.     gr.  j. 

Morphise  hydrochlorat, 

•     gr.j. 

Bismuth  sub-nitrate, 

Sacch.  alb.,     .        .        .       aa       . 

.     5j.  ij. 

M. 


Cocaine  in  Paroxysmal  Sneezing. 

^     Sol.  of  hydrochlorate  of  cocaine  (4  per  cent.),     5j, 

Acid  carbolic, 5j. 

Tinct.  camphora, 5iss. 

Aquee, 5ij.         M. 

Lotion.     Syringe  or  spray  the  nostrils  each  morning  with  posterior 
nasal  syringe  or  spray  apparatus. 


COCAINE    IN    DISEASES    OF    EYE    AND    EAR.       429 

Dr.  Da  Costa  [Med.  and  Surg.  Reporter,  Nov.  7,  1885),  hav- 
ing found  solutions  of  cocaine  favorable  in  rose  cold  or  hay 
fever,  concludes  as  follows  :  That  the  remed}"  is  not  radical,  and, 
strictly  speaking,  curative.  He  has  found  that  it  gives  great 
comfort,  converts  severe  into  light  cases,  enables  to  remain  in 
their  homes  those  who  otherwise  are  obliged  to  flee  to  hay 
fever  resorts,  and  relieves  much  suffering  and  distress. 

After  the  suffering  and  distress  are  relieved  by  the  cocaine 
we  have  found  permanent  relief  from  the  spray  of  a  solution  of 
peroxide  of  hydrogen,  one-half  ounce  to  half  a  pint  of  pure 
water.  The  spray  apparatus  must  be  of  glass  or  rubber,  as  all 
metallic  contact  destroys  the  peroxide  of  hydrogen. 

Cocaine  in  Astlima. 

Mosler,  of  Grreefswald  {Birin.  3Ied.  Review,  p.  2.36,  Nov., 
1886),  points  out  that  cocaine  has  a  central  as  well  as  a  periph- 
eric local  action  on  the  sensory  nerve  endings,  and  this  central 
action  is  at  first  stimulating,  but  afterward  sedative  or  narcotic. 
By  both  these  reactions  cocaine  ought  to  be  of  use  in  asthma. 
Beschorner  has  published  two  cases  in  which  it  was  of  service, 
and  Mosler  in  three  cases  has  obtained  excellent  results.  All 
these  were  uncomplicated,  and  occurred  in  young  people  of 
twenty-three  to  twenty-five  years  of  age.  The  drug  was  given 
subcutaneously  in  two  per  cent,  solution. 


CHAPTER    XIX. 

•Cocaine  in  Diseases  of  the  Eye  and  Ear — Eucaine  Hydrochlorate,  a 
Kew  Local  Anaesthetic. 

The  best  antiseptic  solution  of  cocaine  contains  gr.  -^u^  of 
bichloride  of  mercury,  and  may  be  employed  after  keeping  a 
few  days,  if  made  with  pure  distilled  water.  I  have  found 
that  a  strong  solution  will  cause  a  feeling  of  roughening,  and 
will  detach  the  epithelium  of  the  eye.  This  will  require  an 
infusion   of  pith  of  sassafras,  with  camphorated   tincture   of 


430  ARTIFICIAL    ANAESTHESIA. 

opium  (a  teaspoonful  in  a  coffee  cup  of  the  tea),  to  relieve  the 
disagreeable  symptoms.  The  cocaine  should  be  a  two  per  cent, 
solution,  and  freshly  made  when  required. 

The  question  of  using  a  freshly-prepared  solution  is  of  the 
utmost  importance.  Cases  of  irritation  and  inflammation  often 
occur  after  using  solutions  too  strong  or  containing  mould.  Like- 
wise the  syringe  must  be  kept  scrupulously  clean,  and  after  wash- 
ing and  wiping,  draw  a  few  drops  of  equal  parts  of  olive  oil  and 
liquid  carbolic  acid  up  and  down  the  needle,  then  wipe  it  dry. 

Cocaine  in  Diseases  of  the  Eye. 

Five  cases  of  ordinary  catarrhal  conjunctivitis  were  treated 
successfully,  but  not  worthy  of  being  reported  in  detail. 

Case  Sixth. — Case  of  cyclitis  in  a  young  lady  of  sixteen,  C. 
G. ,  at  school,  with  extreme  pericorneal  congestion.  The  pain 
in  the  eye  was  very  much  relieved  by  dropping  in  a  two  per 
cent,  solution  of  the  hydrochlorate  of  cocaine,  and  congestion 
disappeared  as  if  by  magic.  She  was  directed  colored  glasses, 
and  not  to  use  her  eyes ;  when  the  pain  returned,  to  drop  in  one 
or  two  drops  of  the  same  solution. 

Case  Seventh. — A  gentleman,  T.  L.,  aged  sixty  years,  with 
catarrhal  conjunctivitis,  which  attacks  him  during  autumn  and 
remains  most  of  the  winter,  increased  by  cold  winds  and  read- 
ing by  gaslight.  He  was  suffering  from  a  discharge  in  the 
morning  and  burning  through  the  daj^  I  applied  a  two  per 
cent,  solution  to  the  eye  with  a  brush,  when  he  complained  of 
a  slight  smarting  for  a  few  seconds.  After  the  smarting  had 
disappeared,  he  bore  without  flinching  a  solution  of  boro-glyce- 
ride  to  get  rid  of  the  excessive  secretions  which  blurred  his  vision 
at  night.  It  also  removed  the  red  and  irritable  appearance  of 
the  edges  of  the  eyelid. 

Case  Eighth. — This  case  is  similar  to  No.  6,  only  in  a  lady  of 
thirty-nine,  who  has  a  great  deal  of  writing  to  do,  and  is  em- 
ployed in  a  book-bindery ;  but  a  few  applications  of  the  two  per 
cent,  solution  relieved  her. 

In  two  of  the  eye  cases,  dilatation  of  the  pupil  took  place ; 
but  not  for  some  time  after  full  application  ;  it  caused  slight 
dryness,  but  did  not  interfere  with  the  vision. 


TREATMENT  OF  OONORRH(EAL  OPHTHALMIA.   431 

Case  Nintli. — Case  of  acute  coryza  without  pain,  but  sneezing, 
complained  that  when  the  solution  was  applied  by  means  of  a 
dropper  it  caused  her  pain,  but  there  was  no  return  of  painful 
sneezing,  which  is  in  certain  families  the  forerunner  of  the 
swelling  of  the  mucous  membrane  with  cold  in  the  head. 

Case  Tenth. — A  gentleman,  aged  thirty-seven,  who  has  a 
broken  nose  and  a  hypertrophic  catarrh  on  very  slight  exposure, 
was  attacked  on  the  evening  of  the  23d  of  January  with  great 
oppression.  Having  to  ride  in  the  countrj'  in  an  open  carriage 
and  stand  in  mud  and  ice  for  some  hours,  he  returned  in  the 
evening  with  a  feeling  of  great  distress  and  pain  in  his  head, 
and  mucous  membrane  of  the  nasal  passages  much  swollen. 
Two  applications  of  a  two  per  cent,  solution  of  the  hydrochlorate 
to  the  whole  surface  of  the  posterior  nares  at  intervals  of  five 
minutes,  followed  with  a  five  per  cent,  solution  of  the  alkaloid 
in  oleic  acid,  gave  him  great  relief,  so  that  he  could  breathe 
with  comfort  and  satisfaction.  He  was  then  directed  one-eighth 
grain  of  morphia  sulphas,  and  one-hundredth  of  atropine,  to  be 
taken  at  bed-time. 

24th. — Still  sufi'ering  somewhat  from  the  difficulty  of  the 
breathing  through  the  nostrils,  but  a  repetition  of  the  applica- 
tion of  the  oleate  relieved  him  entirely. 

January  26. — Discharged  the  patient,  cured. 

Case  Eleventh. — Catarrhal  inflammation  of  the  eyelids,  known 
as  blepharitis  marginalis,  with  defective  vision,  in  a  school  girl, 
aged  ten  years.  The  crusts  around  the  eyelids  were  removed 
twice  with  a  warm  two  percent,  solution  of  cocaine,  after  resting 
for  a  time  ;  then  the  eyelids  were  painted  with  a  solution  of 
boro-glyceride ;  these  two  preparations  used  together  entirely 
removed  the  redness  and  gave  great  relief  to  the  little  patient. 
She  was  directed  to  continue  the  use  of  the  solution  of  boro- 
glyceride  for  some  time,  not  to  use  her  eyes,  and  wear  smoked 
glasses  when  in  the  sun. 

Cocaine  in  the  Treatment  of  Gonorrlioeal  Oph- 
thalmia. 

Mr.  x\.  Leahy  reports  (in  the  Indian  Med.  Gazette.,  July, 
1886)  two   cases  of  gonorrhoeal  ophthalmia,  in  both  of  which 


432  ARTIFICIAL    ANESTHESIA. 

the  greatest  benefit  was  derived  from  application  of  cocaine. 
As  it  is  well  known,  in  gonorrhoeal  ophthalmia  it  is  of  primary 
importance  to  lessen  the  inflammation  rapidly,  to  relieve  the 
intense  congestion  of  the  conjunctival  vessels  and  reduce  che- 
mosis,  and  by  so  doing  prevent  ulceration  and  sloughing  of  the 
cornea.  Last,  but  not  least,  is  the  relief  of  the  ocular  and  cir- 
cum-orbital  pain,  which,  by  its  persistence,  greatly  depresses 
the  patient  and  prevents  sleep.  Mr.  Leahy  employed  a  mix- 
ture composed  of  one-half  grain  of  sulphate  of  atropine  and  two 
grains  of  sulphate  of  cocaine  incorporated  with  one  hundred 
grains  of  vaseline.  This  mixture  was  introduced  beneath  the 
upper  ej'^elids,  and  after  three  days'  treatment  the  chemosis 
rapidly  became  less,  the  discharge  diminished  in  quantity,  the 
pain  completely  disappeared,  and  the  cornea,  which  had  been 
hidden  by  the  chemosis,  became  visible. 

Cocaine  and  Atropia  for  Iritis. 

Guaiaila  gives  the  following  as  used  by  many  ophthalmolo- 
gists : 

^     Cocaine  hydrochlor.,         .         .        .         .     gr.  i. 
Atrop.  sulphat.,         .        .        .        .        .    gr.  1. 

Acid  boric, gr.  iv. 

Aquse  destillat.,  .        .        .        -        .     Siiss.      M. 

SiG. — One  or  two  drops  in  the  eye  every  half  hour  until  the  pupil 
dilates. 

— jL'  Union  Medicale,  June  25, 1887. 

On  the  Use  of  the  SoUition  of  Cocaine  Hydrochlo- 
rate  in  Ear  Disease. 

Nov.  20,  Gr.  B.  M.,  M.D.,  applied  for  deafness  in  both  ears, 
but  especially  the  right.  On  examination  found  the  sides  of 
meatus  and  lumen  filled  with  separated  masses  of  scales  several 
millimeters  in  length,  firmly  attached  to  the  parts,  which,  on 
removal  by  the  forceps,  gave  him  great  pain.  He  also  found 
the  pressure  of  the  ear  speculum  painful.  This  was  explained 
after  the  removal  of  a  portion  of  these  diseased  scales  by  find- 
ing the  under  surface  inflamed,  reddened,  and  ready  to  bleed  at 
the  sHghtest  touch  of  the  instrument.     To  obviate  this  pain  and 


COCAINE    HYDROCHLORATE    IN    EAR    DISEASES.  433 

allow  the  entire  removal  of  this  desquamated  material,  a  four  per 
cent,  solution  of  hydrochlorate  of  cocaine  was  instilled  into  the 
ear  every  five  minutes  for  fifteen  minutes.  At  the  end  of  this 
period,  again  began  removing  the  offending  material  without 
so  much  pain  ;  still  it  was  not  a  true  anaesthesia,  and  if  we 
made  strong  pressure  with  the  speculum  in  introducing  it,  it 
also  gave  him  slight  pain  ;  still  he  was  able  to  bear  it  much 
better  with  the  solution,  until  all  was  removed  from  the  right 
ear.  He  was  then  directed  a  sol.  zinci  sulpho-carbolate,  grs. 
iv. ;  morphia  sulphas,  grs.  i.;  iv.  oz.  of  aqua  destillata.  For 
the  left  ear,  after  the  use  of  the  forceps,  gave  an  alkaline  solu- 
tion to  drop  in  ten  drops  three  or  four  times  a  day  and  rest  for 
fifteen  minutes  so  as  to  remove  what  scales  were  on  the  m. 
tympani.  November  23,  washed  out  the  remaining  scales,  and 
inflated  the  middle  ear,  with  great  improvement  of  hearing  in 
both  ears. 

November  25th,  H.  F.  M.,  aged  29,  bank  clerk,  suffering  from 
deafness  and  constant  "  ratthng  or  buzzing,"  from  congestion 
and  hypertrophy  of  the  pharyngeal  tonsils  and  mucous  mem- 
brane of  the  post-nasal  spaces,  which  required  cutting  freely 
with  a  tenotomy  knife.  Before  doing  so  I  applied  a  four  per 
cent,  solution  of  the  cocaine,  and  although  I  made  five  differ- 
ent incisions  into  the  enlargement,  he  was  not  aware  that  it 
was  accomplished  until  he  found  a  few  drops  of  blood  passing 
into  his  oesophagus.  One  week  after  he  reported  by  letter  of 
improvement  in  hearing.  In  this  operation  not  one-fourth  the 
amount  of  blood  was  lost  as  in  such  cases  without  the  cocaine, 
the  parts  remaining  quite  rigid  for  some  time  after  the  opera- 
tion. 

November  29th. — Applied  the  four  per  cent,  solution  to  a  lady 
suffering  from  excessive  secretions  of  glands  of  the  throat,  and 
passing  into  the  Eustachian  tube  causing  noises  of  a  variable 
character.  She  suffered  also  from  swelling  and  hypertrophic 
conditions  of  the  posterior  portion  of  the  nasal  mucous  mem- 
brane and  turbinated  bodies.  The  parts  were  cleansed  with 
spray  of  Dobell's  solution,  and  a  strong  current  of  dry  con- 
densed air  was  employed  to  free  them  from  moisture,  a  flexible 
silver  catheter  was  introduced  first  into  the  right  side  of  the 


434  ARTIFICIAL    ANESTHESIA. 

nose  and  a  nozzle  was  fitted  to  it,  and  then  the  elastic  tube  of 
the  condensed  air  chamber,  and  a  few  drops  of  the  solution  of 
hydrochlorate  of  cocaine  were  introduced  into  the  catheter,  and 
the  parts  spra3'ed  by  forcing  the  air  through  it.  In  the  same 
operation  performed  upon  the  opposite  ear,  there  being  a  devi- 
ation of  the  septum,  there  was  more  pain,  but  very  much  less 
than  when  we  introduced  the  instrument  before.  The  spray- 
ing was  repeated  at  three  different  times,  when  in  about  ten 
minutes  she  felt  the  peculiar  apparent  swelling  and  drying 
effects,  and  great  relief  from  the  noises,  by  the  freedom  with 
which  air  passed  through  the  Eustachian  tubes.  The  lady 
reported,  a  week  after,  improvement  of  hearing  and  more  free- 
dom from  the  noises. 

Eucaine  Hydrochlorate. 

This  is  a  more  recently  discovered  local  anaesthetic,  which 
acts  physiologically  like  cocaine,  but  is  less  poisonous.  The 
pulse  with  eucaine  is  always  decreased  in  frequency;  with 
cocaine  there  is  primary  acceleration.  Eucaine  causes  no 
ischagmia,  but  vascular  dilatation.  Another  difference  is  that 
the  pupils  are  not  affected  ;  midriasis  does  not  occur,  and  the 
reaction  to  light  remains  normal.  The  convenient  name  of 
eucaine  has  been  adopted  in  the  place  of  its  chemical  one  of 
methylester  of  a  benzoylated  oxypiperidin  carbonic  acid.  See 
formula,  p.  39.  Like  cocaine,  its  free  base  is  with  difficulty 
soluble  in  water  and  forms  large  shining  crystals,  melting  at 
104°  to  105°  G.  (220°  to  222°  F.).  With  acids  it  forms  neutral 
salts  having  the  same  action  as  the  base  itself.  The  hydro- 
chlorate, the  salt  which  we  have  employed,  cr^^stallizes  from  a 
watery  solution  in  permanent  shiny  plates  or  scales,  which  con- 
tain one  molecule  of  water  of  crystallization,  and  having  a 
formula  of  0i9H2,NO,HCl.H2O. 

"  Local  Action. — A  two  to  five  per  cent,  solution  of  eucaine 
instilled  into  the  eye  of  an  animal,  as  a  dog  or  rabbit,  caused 
complete  local  anaesthesia  in  from  one  to  three  minutes.  It 
began  in  the  cornea,  and  spread  from  thence  to  the  conjunc- 
tiva, and  lasted  on  an  average  from  ten  to  twenty  minutes.  It 
was  readily  prolonged  by  repeating  the  dose.     It  was  always 


EUCAINE    HYDROCHLORATE.  435 

accompanied  by  a  slight  hyperaemia  and  slight  irritation  of  the 
palpebral  conjunctiva.  This  was  only  the  case  with  the  methyl 
alcohol  form  ;  the  watery  solution  caused  at  most  a  very  slight 
hyperaemia.  The  pupil  was  not  dilated,  and  reacted  well  to 
light.  Injected  under  the  skin,  eucaine  caused  complete  anaes- 
thesia of  the  part,  so  that  the  reflex  could  not  be  evoked  even 
with  a  needle.  A  similar  complete  local  anaesthesia  of  the 
mucosa  was  affected  when  a  eucaine  solution  was  painted 
over  it. 

"  The  general  action  of  the  drug^  both  in  cold  and  warm 
blooded  animals,  consisted  in  a  marked  excitation  of  the  entire 
central  nervous  system,  followed  by  paralysis  in  toxic  doses- 
going  on  to  death.  Even  0.002  cent.  gram.  (-^  grain)  caused 
irritability,  heightened  reflexes,  inco-ordination,  and  finally 
general  paralysis  in  the  animals  experimented  with.  Small 
doses  administered  to  mice  and  rabbits  caused  increased  reflex 
excitability  and  increased  but  weakened  respiratory  movements. 
Medium  doses  of  0.02  to  0.03  cent.  gram.  {^  to  J  grain)  per  kilo- 
gram (35  ounces)  caused  repeated  tonic  and  clonic  convulsions. 
The  animals  lay  senseless  on  their  sides,  with  dyspnoea,  opistho- 
tonos, and  finally  paresis  of  the  posterior  limbs.  These  phe- 
nomena were  most  marked  when  large  toxic  doses  of  0.10  to 
0.15  cent.  gram.  (IJ  to  2\  grains)  per  kilogram  (35  ounces)  were 
administered  ;  the  convulsions  returned  continuously,  and  af- 
fected all  the  muscles  of  the  body.  The  animals  finally  died 
when  the  paralysis  reached  the  respiratory  muscles. 

"When  the  dose  was  not  a  fatal  one,  the  convulsions  gradually 
ceased,  the  increased  reflex  excitability  disappeared,  and  the 
paresis  of  the  hind  limbs  slowly  improved. 

"The  effect  of  eucaine  on  the  central  nervous  system  is  there- 
fore at  first  excitant,  and  later,  in  toxic  doses,  paralyzing.  The 
paralysis  is  a  central  one,  for  if  the  sciatic  nerve  of  a  frog^ 
poisoned  with  eucaine  is  exposed,  and  its  peripheral  end  irri- 
tated with  the  induced  current,  the  limb  reacts  in  a  normal 
manner. 

"As  regards  its  action  on  the  heart  and  the  bloodvessels, 
the  subcutaneous  and  intravenous  injection  of  small  and 
medium  doses  slows  it  on  the  average  from  twenty  to  thirty 


436  ARTIFICIAL    ANiESTHBSIA. 

beats  per  minute,  but  without  otherwise  modifying  the  beats, 
or  increasing  the  blood-pressure.  This  effect  on  the  pulse  is 
caused  by  the  excitation  of  the  central  vagus ;  for  section  of 
the  vagi  causes  an  immediate  increase  of  the  pulse  to  the  nor- 
mal and  above  it,  together  with  an  increase  of  the  blood -pres- 
sure. Death  occurs  from  paralysis  of  the  respiratory  centres, 
for  the  heart  continues  to  beat  for  some  time  thereafter."* 

Eucaine  as  a  Local  Ansestlietic.f 

"Dr.  G.  A'^inci,  of  Messina,  described  eucaine  as  possessing 
the  properties  of  cocaine  as  a  local  anaesthetic,  but  as  being  less 
toxic  and  as  having  no  effect  upon  the  pupil.  The  last  state- 
ment seemed  to  me  to  be  of  practical  importance,  because  a 
dilated  pupil  is  an  impediment  to  the  performance  of  many 
operations  upon  the  eye.  It  has  long  been  my  practice  to  neu- 
tralize the  dilating  effect  of  cocaine  by  a  preliminary  application 
of  eserine,  but  this  course  is  not  entirely  satisfactory.  It  is 
difficult  to  secure  the  precise  degree  of  effect  w^hich  is  desired, 
while  the  eserine  dilates  the  vessels  of  the  iris  and  occasions  free 
bleeding  when  they  are  incised.  It  also  renders  the  iris  tissue 
comparatively  rigid,  so  that  it  is  less  easily  drawn  out  of  the 
anterior  chamber.  I  obtained  a  supply  of  a  five  per  cent, 
watery  solution  of  eucaine  hydrochlorate  from  Mr.  Rodgers,  of 
327  Oxford  Street,  and  used  it  last  week  for  a  cataract  extrac- 
tion, the  patient  being  a  woman.  Before  my  arrival  the  nurse 
had  applied  a  drop  of  the  solution  within  the  lower  lid  every 
five  minutes  for  six  times,  and  I  found  the  eye  perfectly  insen- 
sitive. The  pupil  was  unaffected  and  acted  readily  to  light. 
There  was  scarcely  any  bleeding  from  the  cut  iris  ;  there  was 
perfect  quiescence  of  the  muscles  and  there  was  no  pain.  I 
asked  the  patient  whether  she  had  felt  anything,  and  she  re- 
plied :  '  I  felt  something  moving  about  my  eye,  but  it  did  not 
hurt  me.'  There  was  no  pain  afterwards,  and  healing  was  un- 
interrupted.    I  have  since  successfully  used  a  single  application 

*  Pamphlet  from  Schering  and  Glaze. 

t  By  Eobert  Brudenell  Carter,  F.R.C.S.,  England,  Consulting  Oph- 
thalmic Surgeon  to  St.  George's  Hospital.  From  The  Lancet,  July  11, 
1896. 


EUCAINE    HYDROCHLORATE    IN    THE    EYE.         437 

of  the  same  solution  as  a  preliminary  to  the  removal  of  a  for- 
eign body  imbedded  in  the  cornea. 

"In  the  original  paper  it  is  said  that  eucaine  has  been  suc- 
cessfully used  in  dentistry  and  laryngology,  and  that  solutions 
may  be  injected  hypodermically  without  injury.  My  first  experi- 
ments will  certainly  induce  me  to  use  it  again,  and  for  tenoto- 
mies as  well  as  for  iridectomy  or  extraction.  It  is  said  that  the 
solution,  above  mentioned,  may  be  sterilized  by  boiling  again 
and  again,  if  necessary,  without  undergoing  decomposition  or 
suffering  any  deterioration  of  quality. 

Eucaine  Hydrochlorate  in  the  Eye. 

Having  had  made  a  careful  solution  of  hydrochlorate  of 
eucaine,  two  per  cent.,  in  distilled  water  (a  second  supply  ob- 
tained from  the  regular  agents.  Sobering  &  Glaze),  in  July, 
1896,  it  was  applied  to  the  eye  of  a  patient,  and  it  created  both 
pain  and  lachrymation,  with  no  soothing  an  aesthetic  after-effects 
such  as  is  produced  by  such  a  solution  of  hydrochlorate  of 
cocaine. 

The  following  abstract  from  a  letter,  addressed  to  my  son,  ex- 
plains this  peculiarity : 

"Dr.  George  Merling,  the  discoverer  of  eucaine,  and  likewise 
a  director  of  the  Sobering  Chemical  Works  in  Berlin,  is  of  the 
opinion  that  the  irritation  was  caused  by  some  methyl  alcohol 
contained  in  the  preparation  supplied  heretofore." 

"Eucaine  AND  Cocaine. — In  the  Therajpeutische  Moiiatshefte 
Blatter  for  July  23d,  the  suggestion  is  made,  in  consequence  of 
the  burning  occasionally  caused  by  instilling  a  two  per  cent, 
solution  into  the  eye,  that  Berger's  plan  is  followed,  that  of  in- 
stilhng  first  a  drop  of  a  one  per  cent,  solution,  and  then,  after 
two  or  three  minutes,  a  drop  of  a  two  per  cent,  solution.  Ber- 
ger,  it  is  added,  uses  eucaine  and  cocaine  together,  in  the  fol- 
lowing solution : 

^    Eucaine  hydrocliloride, 

Cocaine  hydrochloride,    .        .  aa  .        .        3  grs. 
Distilled  water, 300  grs.    M. 

"The  exsanguinating  action  of  the  cocaine,  often  undesirable. 


438  ARTIFICIAL    ANESTHESIA. 

is  thus  avoided,  and  its  action  on  the  pupil  and  the  accommo- 
dation is  diminished  one-half." — NewYork  Med.  Jour.,  August 
18,  1896. 

Directions  for  the  Use  of  Eucaine  Hydrochlorate 
in  Dentistry. 

"  1.  Dissolve  1  gramme  (15  grains)  of  eucaine  in  10  grammes 
(150  minims  or  2J  fluidrachms)  of  distilled  water  and  boil  the 
solution.  The  solution  should  be  perfectly  clear,  and  is  best 
preserved  in  a  glass- stoppered  bottle  containing  about  10 
grammes  (2J  fluidrachms). 

' '  2.  Thoroughly  disinfect  the  mucous  membrane  before  the 
extraction  by  cleansing  it  vigorously  with  tampons  of  absorbent 
cotton  soaked  in  peroxide  of  hydrogen  or  other  antiseptic 
solution. 

"  3.  Insert  the  needle  of  the  sj^ringe  close  to  the  edge  of  the 
gum,  and  never  any  higher  than  half-way  the  alveolar  process. 
Enough  fluid  must  be  injected  to  whiten  the  mucosa  in  the  im- 
mediate neighborhood  of  the  puncture  and  cause  a  slight  eleva- 
tion, and  no  more.  Both  a  buccal  and  a  lingual  injection  must 
be  made.  It  is  very  important  that  the  injection  he  not  made  at 
the  point  of  junction  of  the  alveolar  and  buccal  mucous  mem- 
branes. 

"4.  Extraction  is  to  be  done  as  soon  as  the  patient  himself 
feels  the  anaesthesia,  which  is  in  about  one  minute,  and  not  im- 
mediately after  the  injection.  It  should  be  done  carefully  and 
without  the  excessive  application  of  force. 

"5.  After  the  bleeding  has  ceased,  the  remaining  eucaine 
solution  must  be  removed  by  puncturing  the  swelling  with  the 
needle  and  maldng  digital  pressure  upon  the  gum. 

"  6.  Every  extraction  with  resection  is  followed  by  some  little 
swelling.  When  a  good  deal  of  eucaine  has  been  employed, 
and  when  some  of  it  has  gotten  under  the  mucous  membrane 
lining  of  the  bucco-alveolar  furrow,  we  must  warn  the  patient 
that  there  will  be  some  swelling,  which,  however,  will  be  entirely 
painless,  and  will  retrogress  spontaneously  in  one  or  two  days. 
The  oedema  thus  set  up  is  entirely  harmless;  it  disappears  quickly 
and  without  pain,  and  is  never  accompanied  by  any  by-effects. 


EUCAINE    IN    MINOR    SURGERY.  439 

"7.  Before  making  an  injection,  care  should  be  taken  to  ex- 
clude any  air  contained  in  the  syringe.  That  is  accomplished 
by  holding  the  syringe  needle  upwards,  and  allowing  a  drop  or 
two  of  the  solution  to  ooze  out." 

Report  on  Eiicaine  in  Dentistry.* 

"Dr.  Laurence  Turnbull: 

^^  Dear  Doctor :  As  requested,  I  have  tested  the  '  eucaine  ' 
which  you  furnished  me  in  such  cases  as  came  under  my  care  in 
the  clinic.  I  also  gave  some  to  a  gentleman  who  has  a  large 
extracting  practice  (using  cocaine,  one  per  cent.).  The  solution 
used  in  all  cases  was  a  two  per  cent,  eucaine  in  distilled  water, 
and  about  fifteen  or  twenty  drops  injected.  It  has  proven  very 
satisfactory,  quite  as  much  so  as  cocaine,  in  its  local  effects,  and 
so  far  no  ugly  symptoms  have  shown  themselves.  About  fifteen 
persons  have  had  it  injected,  some  for  a  number  of  teeth  at  one 
time.     I  did  not  note  the  pulse  effects." 

Dr.  A.  A.  Shaw,  dentist,  615  Massachusetts  Avenue,  Cam- 
bridgeport,  Mass.,  states,  under  date  of  June  IT,  1896:  "I 
have  used  eucaine  hydrochlorate  in  a  number  of  patients  with 
gratifying  results  :  so  much  so  that  I  intend  to  continue  its  use. 
I  am  keeping  the  records  of  cases,  and  expect  to  make  a  report 
of  the  same  for  one  of  the  dental  journals.  One  thing  I  notice 
particularly  is  its  prompt  action  and  no  after-effects." 

Dr.  Walter  Fleming,  Hotel  Imperial ,  Broadway  and  Thirty- 
Second  Street,  New  York,  states,  under  date  of  June  1,  1896  : 
"  I  have  used  it  but  once,  but  that  very  satisfactory,  and  I  shaU 
continue  it  in  preference  to  cocaine." 

Eucaine  in  Minor  Surg-ery— Report  of  a  Case.f 

"  While  cocaine  has  been  of  undoubted  value  in  minor  sur- 
gery, its  use  having  enabled  the  surgeon  to  dispense  with  gene- 
ral anaesthetics  in  lesser  operations,  many  cases  have  been  re- 
ported in  which  its  exhibition,  even  in  very  small  quantities, 
has  been  attended  with  serious  and  even  fatal  results.     If  these 

*  By  Otto  E.  Inglis,  Philadelphia  Dental  College, 
t  By  Arthur  L.  Fuller,  M.D.,  Houston,  Texas. 


440  ARTIFICIAL    ANAESTHESIA. 

accidents  were  due  to  the  use  of  excessive  quantities  of  the 
drug  they  could  be  guarded  against ;  but  the^'  seem  to  have 
occurred  quite  independently  of  the  amount  used,  and  this  un- 
certainty of  action  has  undoubtedly  caused  many  surgeons  to 
employ  it  less  than  they  otherwise  would  have  done. 

"  It  is  claimed  that  in  eucaine  we  have  a  drug  which  is  prac- 
tically innocuous  and  which  produces  a  local  anaesthesia  fully 
as  effective  as  that  of  cocaine.  While  the  reports  of  its  use  in 
ophthalmic  and  dental  practice  show  that  it  has  a  very  strong 
claim  on  our  attention,  very  few  reports  of  its  use  in  general 
surgery  have  so  far  come  to  hand,  and  this  emboldens  me  to 
report  a  case  which  is  interesting  solely  from  its  employment 
as  an  anaesthetic. 

"Miss  J,  L. ,  aged  18,  came  to  me  with  a  large  mole  on  her 
neck.  The  mole  was  so  situated  as  to  show  above  the  back  of 
her  dress,  and  caused  her  much  distress  on  account  of  its  un- 
sightliness.  After  injecting  endermically  twenty  minims  of  a 
ten  per  cent,  solution  of  eucaine,  I  made  an  elliptical  incision 
through  the  skin  and  removed  the  mole,  together  with  a  little 
surrounding  skin.  The  piece  removed  was  somewhat  larger 
than  a  quarter  dollar.  The  edges  were  then  brought  together 
with  two  sutures  and  a  simple  dressing  applied.  On  the  third 
day  the  sutures  were  removed  and  the  wound  covered  with  col- 
lodion. The  place  is  now,  eight  days  after  removal,  quite 
healed,  only  a  thin  red  line  marking  the  site  of  the  operation. 

"  In  this  case  the  anaesthesia,  which  covered  an  area  as  large 
as  a  half-dollar,  was  rapidly  induced  and  absolutely  perfect,  the 
patient  not  even  knowing  when  the  incisions  were  being  made 
or  the  sutures  introduced,  though  the  tissues  were  so  hardened 
by  the  eucaine  that  it  was  only  with  difficulty  the  needles  could 
be  made  to  pierce  it.  Such  perfect  anaesthesia  I  have  never 
seen  induced  by  endermic  injections  of  cocaine.  I  observed  no 
bad  effects  on  the  circulation,  though  from  the  position  of  the 
mole  there  was  no  means  of  preventing  the  whole  amount  of 
eucaine  entering  the  circulation  in  a  very  short  time,  and  there 
were  no  bad  after-effects,  the  wound  healing  well  and  quickly. 

"This  case  has  given  me  a  very  favorable  impression  of 
eucaine,  and  I  shall  in  future  almost  entirely  substitute  it  for 


CHLORIDE    OF    ETHYL.  441 

cocaine  in  my  practice,  reserving  the  latter  for  those  cases  in 
which  sutures  are  required,  for  while  eucaine  seems  to  be  the 
superior  in  the  thoroughness  of  the  anaesthesia  induced,  it  so 
hardens  the  tissue  that  it  is  only  with  the  greatest  difficulty 
that  sutures  can  be  introduced,  a  drawback  which  may  possibly 
be  overcome  by  the  use  of  weaker  solutions,  if  such  are  found 
to  act  as  well  as  the  one  used  in  this  case. 

"  Since  writing  the  above,  my  friend,  Dr.  E.  N.  Gray,  of  this 
city,  has  described  to  me  a  case  in  which  he  used  eucaine.  The 
patient  was  suffering  from  a  tubercular  ulcer,  and  he  wished  to 
scrape  away  the  diseased  tissues.  He  tried  painting  the  sur- 
face of  the  ulcer  with  a  four  per  cent,  solution  of  cocaine,  but 
it  had  so  little  effect  that  the  patient  could  not  bear  the  scrap- 
ing. Some  days  later  he  tried  an  eight  per  cent,  solution  of 
eucaine  and  was  able  to  curette  the  nicer  freely  with  no  discom- 
fort to  the  patient.  He  states  that  the  anaesthesia  was  perfect, 
that  it  was  induced  more  rapidly,  extended  more  deeply  and 
lasted  longer  than  that  of  cocaine.  His  experience  coincides 
with  mine  as  regards  the  hardening  of  the  tissues,  and  he  in- 
forms me  that  the  eucaine  coagulated  the  pus,  so  that  it  came 
away  like  lumps  of  cheese."* 


CHAPTER   XX. 


Chloride  of  Ethyl,  or  Ether  Chlorhydric— Characters.  Mode  of  Prep- 
aration, Discovery.  Experiments  of  Clover— Mono-Chlorethane— 
Wigger's  Anaesthetic  Ether— Chloride  of  Ethyl  as  a  Local  Anses- 
thetic— Objections  to  Powerful  Eefrigerative  Agents— Experi- 
ments with  Chloride  of  Ethyl  and  Pental  by  Dr.  H.  C.  Wood  and 
David  Cerna,  M.D.— Compounds,  Phenol,  Camphor,  Menthol,  and 
Eesorcin — Antipyrine  as  a  Local  Anaesthetic. 

The  chloride  of  ethyl  (C4H5CI)  is  a  neutral  liquid,  very  mo- 
bile; has  an  agreeable  and  penetrating  odor.  Its  density  at 
zero  —  0.921,  boils  12°  C.  Little  soluble  in  water;  very  solu- 
ble in  alcohol.     It  does  not  precipitate  the  salts  of  silver  even 

*  International  Journal  of  Surgery  vol.  ix.,  September,  1896,  No.  9. 

29 


442  ARTIFICIAL    ANESTHESIA. 

in  alcoholic  solutions.     Its  vapor  burns  with  a  blue  flame,  pro- 
ducing chlorohydric  acid  preparation.    It  is  prepared  as  follows  : 

We  introduce  it  into  a  receiver,  with  two  parts  of  marine  salt, 
pouring  equal  parts  of  alcohol  and  sulphuric  acid.  It  is  then 
slightl}^  heated.  Shortly,  the  chloride  of  ethyl  is  disengaged  in 
a  gaseous  form.  It  is  then  washed  in  a  vase  containing  tepid 
watei',  and  dried  by  causing  it  to  pass  through  tubes  containing 
chloride  of  calcium,  and  is  finally  condensed  in  a  vase  sur- 
rounded by  a  refrigerative  mixture.  The  product  is  very  easily 
altered,  and  should  be  preserved  in  a  long  narrow-necked  bottle, 
and  sealed  by  the  heat  of  the  lamp  hermetically. 

It  is  also  prepared  by  the  method  of  M.  P.  Mounet,  of  Lyons.  "^ 

"In  a  boiler  of  iron  or  steel,  with  a  perforated  lid  of  200 
litres  of  capacity,  there  is  introduced  alcohol  pure  92° — 55 
kilos;  acid  chlorhydrique.  of  commerce  at  22°  Baume — 110 
kilos.  The  boiler  is  furnished  with  a  menometer  and  a  ther- 
mometer, and  a  spigot  to  disengage  or  flow  ofl".  The  boiler  is 
hermetically  closed,  and  the  mixture  is  heated  for  two  hours  to 
125°  C.  The  pressure  on  the  boiler  amounts  to  25  atmospheres. 
Having  allowed  it  to  cool  to  about  60°,  they  open  the  spigot, 
which,  by  a  tube  of  copper,  is  put  in  communication  with  the 
boiler  and  the  refrigerant  of  ice  and  broken  salt,  which  sur- 
rounds the  worm  of  the  still.  Chloride  of  ethyl  is  rapidly  dis- 
tilled. To  have  it  completely  pure,  it  is  rectified  by  passing 
through  water  slightly  alkaline,  and  it  is  then  placed  in  closed 
glass,  ready  for  use  as  a  local  anaesthetic  in  the  proportion  of  ten 
grammes  each." — Marcel  Baiideuii,  Progress  Medicale. 

Chloride  of  ethyl  was  discovered  in  1795  by  the  Dutch 
chemists  Deimann,  Troostwyk,  Bondt  and  Lawernburg.  Snow 
employed  it  as  an  anaesthetic  first  in  England  in  1851,  then 
Simpson,  Clover  and  Nunnelej'^  in  England,  followed  by  Lieb- 
reich,  Langenbach  and  Steff"en  in  Grermany,  who  subsequently 
availed  themselves  of  it  and  published  their  observations. 
After  this  then  followed  researches  made  by  a  committee  of 
the  British  Medical  Association,  and  the  following  were  their 
conclusions  which  were  reported  on  the  properties  of  this  anaes- 

*  Anaesthesia.  Par  A.  Auvard  aud  E.  Caubet,  Paris,  EueffetCo., 
106  Boulevard  St.  Germaiu. 


CHLORIDE    OF    ETHYL.  443 

thetic.  The  following  effects  were  observed  on  frogs  :  Anaes- 
thesia was  produced  in  four  minutes,  the  heart  beating  natur- 
&\\y  for  thirty-six  minutes ;  on  hot-blooded  animals  the  move- 
ment of  the  heart  experienced  no  modification.  A  compara- 
tive trial  was  then  made  between  the  chloride  of  ethyl  and 
chloroform  on  a  dog,  which  demonstrated  in  the  anaesthesia  of  the 
chloride  of  ethj-l  that  the  rhythm  of  the  heart  was  not  disturbed, 
but  when  the  chloroform  was  substituted  the  heart  became 
rapidly  dilated  and  beat  immoderately,  and  the  cardiac  force 
diminished  rapidly.  The  committee  concluded  that  the  dog 
could  live  for  a  longer  time  under  the  anaesthetic  effects  of  the 
chloride  of  ethyl,  while  it  would  soon  die  under  the  influ- 
ence of  the  chloroform.  On  man  we  observe  the  following 
effects  after  inhalation  :  We  notice  an  agreeable  heat  which  ex- 
tends over  the  body.  In  one  or  two  minutes  the  sensation  be- 
comes confused,  with  tinnitus  aurium  and  whistling  and  buzz- 
ing. Then  a  certain  muscular  rigidity  appears  and  then  anaes- 
thesia commences.  The  patient  is  longer  in  becoming  conscious 
than  in  chloroform,  but  the  after-effects  are  less.  Vomiting  is 
frequent,  but  is  less  painful  and  lasts  a  shorter  time  than  with 
chloroform.  Clover  has  made  extensive  use  of  it,  and  has 
had  but  one  death  in  1877  anassthesias.  He  prefers  to  com- 
mence the  inhalation  by  the  use  of  the  nitrous  oxide,  and  con- 
tinue by  the  chloride  of  ethj^l.  When  you  give  it  alone  it  is 
better  to  continue  it  alone  until  the  period  of  agitation  is  passed, 
and  administer  it  with  prudence,  withdrawing  it  every  three  or 
four  inhalations.  Anaesthesia  is  induced  in  between  three  to 
five  minutes.  Dilatation  of  the  pupil  will  indicate  the  moment 
when  we  should  cease  the  inhalations.  See  more  recent  experi- 
ments with  this  agent  by  Prof  H.  C.  Wood,  on  page  445. 

Mono-Chlorethane.  — It  is  made  by  the  action  of  alcohol 
and  hydrochl.  acid  and  C2H5CI.  It  is  a  gas  at  ordinarj"  tempera- 
ture, and  is  compressed  into  a  liquid  ;  burns  with  a  green  flame  ; 
specific  gravity,  0.918  at  8°  C;  boils  at  122°  C.  To  be  held 
from  six  to  ten  inches  away  from  surface  to  be  sprayed  ;  spray 
b}'  the  heat  of  the  hand.  It  is  highly  inflammable.  Another 
chloride  is  known  as  the  polychlorate  or  Wigger's  anaesthetic 
ether,  which  is  a  mixture  of  chlorinated  ethyl ;  chlorides  chiefly 


444       *  ARTIFICIAL    ANESTHESIA. 

trihedra  and  penta.  Chlorethane,  clear  liquid,  ethereal ;  sweet, 
aromatic  taste ;  local  anaesthetic ;  non-irritant  uses ;  chiefly 
employed  externally  in  rheumatism  and  sciatica. 

Chloride  of  Etbyl  as  a  Local  Ansestlietic. 

The  chloride  of  ethyl  is  a  local  anaesthetic,  and  can  be  em- 
ployed without  danger  sprayed  on  the  skin.  It  produces  a 
rapid  lowering  of  the  temperature  of  the  skin,  and  a  complete 
anaesthesia  of  the  region  touched  and  its  adjacent  parts.  The 
surgeon  must  first  cover  the  skin  with  a  greasy  body  like  glycerine 
or  collodion,  to  avoid  the  direct  irritating  action  of  the  chloride 
of  ethyl,  as  it  sometimes  causes  a  sharp  pain  in  the  parts, 
especially  if  they  have  been  irritated  before. 

Objections  to  PoAverful  Refrig-erative  Agents. 

The  most  serious  objection  to  all  powerful  refrigerative  agents 
is,  that  they  reduce  the  temperature  of  the  skin  and  adjoining 
tissue,  and  if  carried  to  the  condition  of  an  appearance  of  pork- 
like nature,  when  circulation  is  restored  sloughing  is  very  apt  to 
take  place,  and  with  it  the  death  of  the  skin.  Our  object  in 
employing  these  agents  is  to  give  confidence  to  the  patient  that 
the  pain  will  not  be  severe,  and  as  small  a  quantity  as  possible 
should  be  employed. 

Chloride  of  Ethyl  and  Pental.* 

' '  The  editor  of  the  Dental  Cosmos  has  submitted  to  us  the  two 
agents  whose  names  head  this  article,  with  the  request  that  we 
should  investigate  their  physiological  properties  sufficiently  to 
determine  the  question  whether  they  can  be  of  service  as  prac- 
tical anaesthetics.  The  present  paper,  therefore,  is  not  an  ex- 
haustive scientific  study  of  the  physiological  action  of  these 
two  drugs.  Chemists  are  so  multipljdng  compounds,  that  if 
each  compound  is  to  be  thoroughly  studied  by  the  physiologist 
the  result  would  hardly  be  contained  in  the  world's  literature, 

*  By  Horatio  C.  Wood,  M.D.,  and  David  Cerna,  M.D.  Eead  June 
22,  1892.  Eeprinted  from  the  Transactions  of  the  Philadelphia 
County  Medical  Society. 


CHLORIDE    OF    ETHYL.  445 

and  it  is  only  worth  while  in  the  first  place  to  carry  these  inves- 
tigations far  enough  to  determine  the  practical  importance  of 
new  agents.  This  much  excuse  for  what  may  seem,  to  the 
pure  physiologist,  the  lack  of  completeness  of  the  present 
study. 

"  In  such  an  investigation  as  the  present,  the  first  point  to  be 
determined  is  whether  the  substance  has  anaesthetic  properties  ; 
the  second  question  is  whether  the  anaesthesia  produced  is  fuga- 
cious or  permanent ;  the  third  question  is  whether  the  anaes- 
thesia is  accompanied  by  danger  to  life. 

Chloride  of  Ethyl. 

"  Chloride  of  ethyl  is  at  present  largely  used  as  a  local  anaes- 
thetic agent,  which  acts  not  by  virtue  of  any  inherent  anaesthetic 
properties,  but  on  account  of  the  intense  cold  produced  by  its 
extraordinarily  rapid  volatilization.  The  extreme  volatility  of 
the  chloride  almost  proves,  a  priori,  that  any  effect  which  it 
may  have  upon  the  human  system  will  be  of  correspondingly 
brief  duration,  since  very  volatile  substances  are  thrown  off 
from  the  lungs  with  rapidity.  This  a  priori  reasoning  is  en- 
tirely confirmed  by  our  direct  experiments. 

"  We  have  found  it  difficult,  with  out  the  construction  of  special 
inhalers  for  the  use  of  large  quantities  of  chloride,  to  produce 
anaesthesia  in  the  dog  by  the  ordinary  method  of  administra- 
tion. The  chloride  disappears  from  an  inhaler  which  allows 
free  access  of  air,  almost  as  fast  as  it  can  be  poured  on.  We 
have  used  it  in  two  ways.  In  the  one  method  we  connected  a 
large  rubber  tube  with  a  cannula  placed  in  the  trachea  of  the 
dog,  and  then  squirted  the  ansesthetic  into  the  tube  in  such  a 
manner  that  it  would  diffuse  itself  over  the  walls  of  the  tube 
for  a  considerable  distance.  The  administration  in  this  way  of 
ten  grammes  of  the  chloride  of  ethjd  failed  to  produce  distinct 
anaesthesia  in  the  dog,  although  the  respiration  was  affected 
and  some  fall  of  the  arterial  pressure  occurred.  We  append 
details  of  two  experiments. 

'"''Experiment  I, — Dog,  weight  twelve  kilogrammes.  Griven  ten 
grammes  by  inhalation,  thrown  into  the  tracheal  tube  in  about 
three  minutes.     During  this  time  the  circulation  varied  at  dif- 


446  ARTIFICIAL    ANAESTHESIA. 

ferent  periods  considerably.     No  anaesthesia   was    produced.. 
The  arterial  pressure  was  at  first  reduced. 

''"Experiment  II. —  Dog.  Normal  pressure,  190  mm.;  pulse 
rate,  120.  Ten  grammes  chloride  of  ethyl  introduced  in  tra- 
cheal tube  as  rapidly  as  possible.  After  an  inhalation  of  twenty 
seconds:  pressure,  185;  pulse  rate,  144,  Seventeen  seconds 
later  the  pulse  began  to  grow  slow  and  the  pressure  to  fall. 
Eleven  seconds  later  :  mean  pressure,  155;  pulse  rate,  72;  the 
individual  waves  varying  from  one  to  two  cm.  in  height.  This 
condition,  with  gradual  rise  of  pressure,  continued  for  a  minute, 
when  the  pressure  rose  to  190  and  the  pulse  rate  to  140.  No 
anaesthesia  was  produced. 

"  This  experiment  shows  that  the  chloride  of  ethyl  is  capable 
of  acting  as  an  anaesthetic,  provided  that  its  vapor  be  given  in 
concentrated  form.  Why  anaesthesia  was  not  produced  by  the 
second  inhalation  of  ten  grammes  is  not  clear,  but  we  believe 
that  it  was  because  air  was  taken  m  more  freely,  owing  to  the 
cone  not  having  been  placed  tightly  over  the  nose  of  the  animal. 
The  results  of  this  experiment  indicate,  first,  that  the  efi'ect  of 
the  drug  is  exceedingly  fugacious,  since  ten  grammes  failed  to 
produce  a  complete  anaesthesia  of  more  than  two  minutes'  du- 
ration— this,  further,  in  spite  of  the  fact  that  air  was  not  fur- 
nished with  sufficient  freedom  to  yield  the  full  supply  of  oxygen 
to  the  blood ;  second,  that  the  anaesthesia  is  accompanied  with  a 
marked  fall  in  the  rate  of  the  pulse  and  the  force  of  the  arterial 
pressure,  the  pressure  having  fallen  forty-eight  millimetres  and 
the  pulse  forty-five  per  minute  at  the  coming  of  the  first  anaes- 
thesia, whilst  in  the  third  inhalation,  shortly  after  the  loss  of 
the  reflexes,  the  pressure  stood  at  ninety,  instead  of  the  normal, 
one  hundred  and  sixty. 

"  Owing  to  the  comparatively  small  amount  of  the  chloride  of 
ethyl  put  at  our  disposal,  in  the  further  study  of  the  chloride 
of  ethyl  we  confined  ourselves  to  administering  the  drug  by  in- 
jecting it  into  the  jugular  vein.  This  method  of  experimenta- 
tion has  the  advantage  of  greater  exactness  in  dosage,  and  the 
results  are  entirely  parallel  with  those  which  follow  the  admin- 
istration of  the  remedy  through  the  lungs. 

"  It  is  plain,  that  whether  a  drug  be  injected  directly  into  the 


CHLORIDE    OF  'eTHYL.  447 

jugular  vein,  or  whether  it  enter  the  system  Ijy  absorption  into 
the  pulmonic  capillaries,  it  must  first  reach  the  heart  before 
being  diffused  throughout  the  general  circulation.  In  the  one 
case  the  drug  passes  first  into  the  right  side  of  the  heart,  whilst 
in  the  other  case  it  goes  into  the  left  side  of  the  heart.  The 
anaesthesia  which  follows  the  injection  of  the  chloride  of  ethyl 
into  the  jugular  vein  is  very  fugacious,  as  is  shown  in  the  fol- 
lowing tracing,  which  demonstrates  the  effects  of  the  injection 
of  two-tenths  of  a  gramme  into  the  jugular  vein.  The  liquid 
was  injected  between  the  two  crosses ;  the  anaesthesia,  as  de- 
monstrated by  the  loss  of  the  cornea  reflexes,  appeared  at  the 
first  'o'  and  disappeared  at  ^ox,^  having  therefore  lasted 
less  than  half  a  minute.  It  will  be  seen  that  the  amount  of  the 
anaesthetic  was  sufficient  to  reduce  the  circulation  to  a  very 
dangerous  degree. 

"The  effect  of  chloride  of  ethyl  upon  the  respiration  is  very 
marked.  If  the  dose  has  been  sufficient  to  produce  anaesthesia, 
the  respiration  at  first  is  often  stimulated  in  the  extent  of  the 
movements  as  well  as  in  the  number  per  minute.  Thus,  in  one 
experiment,  the  normal  respiration  being  50,  the  rate  became 
60;  in  another,  the  rate  increased  from  70  to  80,  without,  how- 
ever, any  increase  in  the  extent  of  the  movements  ;  a  little  later 
in  this  experiment,  the  animal  still  being  anaesthetized,  the  num- 
ber of  the  respirations  fell  to  40  per  minute,  but  became  nearly 
quadrupled  in  size.  In  still  another  experiment  the  respiration 
before  the  injection  was  60  per  minute,  and  after  the  injection, 
during  the  early  anesthesia,  was  still  60  per  minute,  but  the 
excursions  of  the  needle  connected  with  Marey's  tambour  were 
three  times  the  size  of  what  they  had  been  before  the  admin- 
istration of  the  drug.  In  a  fourth  experiment  the  respira- 
tions before  ansesthesia  were  70  per  minute ;  during  the  early 
anaesthesia,  120  per  minute;  a  few  seconds  later,  100  per 
minute  ;  the  movements  of  the  needle  being  at  the  same  time 
enormously  increased. 

' '  In  all  our  cases  the  fall  of  blood-pressure,  after  the  injection 
of  chloride  of  ethyl,  has  been  immediate  and  excessive  ;  the 
blood-pressure  has  continued  low  without  rise  during  the  whole 
period  of  anaesthesia,  but  has  returned  rapidly  to  the  normal  as 


448  ARTIFICIAL    ANESTHESIA. 

anaesthesia  wore  off.  The  cardiac  beats  have  always  at  first 
been  arrested,  but  subsequently  have  become  of  enormous  size, 
and  continued  so  almost  to  the  end,  as  is  shown  in  the  accom- 
panying reproduction  of  a  tracing.  The  pulse-waves  were  also 
at  this  time  absolutely  consonant  with  and  proportionate  to  the 
respiratory  movements. 

"  We  believe  that  our  research  has  demonstrated,  first,  that  the 
chloride  of  ethyl  is  capable  of  acting  as  an  anassthetic,  but  that 
it  is  eliminated  with  extraordinary  rapidity,  and  that  its  action 
is  extremely  fugacious ;  second,  that  the  anaesthesia  which  it 
produces  is  always  accompanied  by  a  fall  of  the  blood-pressure, 
which  is  probably  at  least  in  part  due  to  the  direct  depressing 
effect  of  the  drug  upon  the  heart ;  third,  that  the  action  of  the 
drug  upon  the  circulation  is  in  no  way  dependent  upon  its  influ- 
ence upon  respiration,  although  it  is  not  certain  that  the  pro- 
nounced depression  of  the  blood-pressure  is  not  a  factor  in  influ- 
encing respiratory  movement ;  fourth,  that  at  least  in  the  dog, 
chloride  of  ethyl  produces  at  first  an  increase  of  the  respiratory 
movement  either  in  rate  or  amount,  or  more  commonly  in  each 
respect,  but  that  finally  respiration  becomes  slow,  and  at  last 
stops  almost  abruptly;  fifth,  that  usually,  if  not  always,  the 
cessation  of  heart-beat  and  the  arrest  of  respiratory  movement 
occur  as  nearly  simultaneously  as  may  be. 

'  'As  the  result  of  the  various  experiments  which  we  have  made 
with  chloride  of  ethyl,  we  believe  that  the  fugaciousness  of  the 
action  of  the  drug  must  interfere  with  its  use  as  a  general  anaes- 
thetic, and  that  its  depressing  effect  upon  the  circulation  is  too 
pronounced  for  it  to  be  a  safe  anaesthetic.  It  is  most  probable 
that  if  it  should  come  to  be  employed  in  practical  medicine  as 
an  anaesthetic,  there  would  be  a  record  of  sudden  deaths  through 
cardiac  failure  proportionately  even  more  numerous  than  those 
caused  by  chloroform .  On  the  other  hand,  our  research  indi- 
cates very  strongly  that  the  small  amount  of  chloride  of  ethyl 
which  is  used  in  producing  local  anaesthesia  for  dental  purposes 
has  practically  no  effect  upon  the  human  system,  any  of  the 
drug  that  is  absorbed  into  the  system  being  eliminated  in  the 
course  of  a  few  minutes. ' ' 


PENTAL. 


449 


Pental, 

"With  pental  we  have  made  a  few  experiments,  both  by  in- 
halation and  injection  into  the  veins.  Though  the  number  of 
these  experiments  is  not  great,  they  seem  to  us  sufficient  to 
show  that  pental  as  an  anassthetic  acts  quickly  and  fugaciously, 
but  that  it  will  probably  be  found  more  dangerous  than  the 
chloride  of  ethyl,  and  much  more  dangerous  than  chloroform. 
We  append  a  tabular  statement  of  one  of  the  experiments  made 
by  inhalation. 

Experiment  VII. — Dog,  weight  12.345  kilogrammes. 


1 

Time. 

ATin       Clan 

Pres- 
sure, 

Pulse 
per 

Respira- 
tion 

Remarks. 

Mm. 

mm. 

per  min. 

0 

154 

138 

30 

0 

20 

Inhalation  of  contents   of  bottle  (10 
grammes  of  drug). 

1 

20 

130 

96 

63 

9 

00 

140 

96 

51 

Reflexes  weak. 

3 

10 

150 

150 

60 

Inhalation  of  contents  of  second  bot- 
tle. 

4 

10 

100 

135 

54 

Complete  ansesthesia. 

6 

40 

150 

60 

57 

Reflexes   returned.     Great     excite- 
ment of  animal. 

11 

40 

160 

Inhalation  of  contents  of  third  bot- 
tle. 

12 

10 

90 

102 

72 

13 

]0 

90 

188 

75 

Complete  anaesthesia,  but  respiration 
somewhat  shallow. 

14 

10 

116 

192 

69 

Reflexes   returned.      In   four   min-  j 
utes   later   animal   had   regained  ■ 
complete       consciousness,       and 
showed    great   excitement.     Was 
afterward  killed. 

"An  examination  of  the  record  of  the  experiment  just  given 
will  show  that  the  production  of  anaesthesia  with  pental  was 
each  time  accompanied  by  a  marked  fall  of  the  arterial  pressure. 
Thus,  in  the  first  inhalation,  the  pressure  had  fallen  from  154 
to  100  mm.,  when  anaesthesia  was  complete  ;  whilst  during  the 
second  anaesthesia  the  pressure  fell  from  160  to  90.  In  each 
anaesthetization  the  respiratory  rate  was  increased,  although  the 
extent  of  the  respiratory  movements  most  of  the  time  were  not 
distinctly  above  the  normal. 


450  ARTIFICIAL    ANAESTHESIA. 

"In  no  case  have  we  caused  death  by  the  inhalation  of  pental, 
but  the  accompanying  tracing  records  the  pulse-wave  and  the 
respiratory  movements  under  the  influence  of  a  lethal  dose  of 
pental  (two  grammes)  injected  into  the  jugular  vein." 

"In  our  experiments  in  demonstrating  the  great  effect  of 
pental  upon  the  heart,  it  is  shown  that  the  heart  was  at  once 
affected  much  more  severely  than  the  respiratory  centres,  that 
they  failed  to  recover  themselves,  and  stopped  beating  before 
the  arrest  of  respiration;  indeed,  full,  deep  inspiration  occurred 
a  half-minute  after  complete  arrest  of  the  circulation. 

"  In  conclusion,  we  are  led  by  our  experiments  to  believe  that 
pental  will  probably  prove  to  be  a  dangerous  anaesthetic,  and  if 
extensively  used,  will  produce  death  by  cardiac  arrest.  It  is 
probable,  also,  that  the  after-effects  of  pental,  in  the  human 
being,  would  be  disagreeable  ;  at  least  we  repeatedly  noticed  in 
the  dog  a  peculiar  wild  excitement  directly  after  the  anaesthesia 
from  pental  had  gone  off." 

"Phenol  and  Camphor. — By  various  combinations  of  phe- 
nol and  camphor.  Dr.  Shaffer  has  formed  a  number  of  local  an- 
aesthetics, which  have  been  found  very  useful  in  minor  surgery 
of  the  ear,  throat,  nose  and  teeth. 

"  The  first  one  is  the  'Phenol  Camphor,'  '  Carbolated  Cam- 
phor,' 'Phenolated  Camphor,' and  'Campho-Phenique. '  When 
common  or  Japanese  camphor  and  crystallized  carbolic  acid 
were  mixed  together  and  heated,  a  colorless  liquid  resulted, 
possessing  antiseptic  and  local  anaesthetic  properties. 

"  We  have  employed  this  agent,  on  the  suggestion  of  Dr.  S. 
MacCuen  Smith,  on  a  dossei  of  antiseptic  cotton,  introduced  in 
the  auditory  meatus,  in  the  second  stage  of  the  troublesome 
form  of  furunculous  inflammation,  or  when  the  furuncle  has 
pointed  and  has  discharged,  or  been  opened  by  a  bistoury  under 
careful  anaesthetic  precautions.  By  this  agent  we  get  rid  of 
the  hypertrophy  of  the  canal  and  relieve  pain. 

"There  are  many  other  forms  of  these  combinations  also, 
When  menthol  is  acted  upon  by  chloral,  trichloric-acetic  acid 
and  thymol,  when  heated  with  camphoi",  it  forms  a  transparent 
oily  fluid ;  also  menthol  with  camphor,  first  described  by  Dr.  S. 
Scott  Bishop,  and   employed  by  him   in   ear  and   throat  dis- 


MENTHO-PHENOL.  451 

eases.     The  last  of  these  forms,  described  by  Dr.  Shaifer,  is  as 
follows : 

Meiitlio-Plienol. 

"  Mentho-phenol,  as  its  name  indicates,  is  obtained  by  adding 
one  part  of  phenol  to  three  parts  of  menthol,  and  then  melting 
the  mixture.  A  transparent  liquid  is  obtained,  having  an  aro- 
matic odor  and  taste.  Applied  to  the  tongue,  it  produces  a 
temporary  anaesthesia  similar  to  that  of  cocaine,  although  not 
so  lasting  as  the  latter.  It  is,  of  course,  lighter  than  water, 
having  a  specific  gravity  of  0.973.  It  is  nearly  insoluble  in 
water  and  glycerine,  but  it  readily  dissolves  in  alcohol,  ether, 
chloroform  and  most  of  the  light  and  heavy  oils.  It  dissolves- 
iodine,  iodoform  and  aristol.  Water  of  ammonia,  mixed  with 
mentho-phenol,  changes  it  to  a  dark  vinous  color  in  a  few  days. 
It  is  antiseptic,  with  strong  analgesic  properties.  It  may  be 
used  preparatory  to  cauterizing  chancroidal  sores  and  curetting 
necrotic  surfaces.  As  a  mouth-wash,  it  may  be  used  with 
advantage,  two  drops  being  mixed  with  an  ounce  of  the  aqueous 
menstruum. 

' '  The  most  admirable  results  have  been  obtained  by  Dr.  Edward 
H.  Shaffer,  in  minor  surgery,  such  as  abscesses,  using  a  mentho- 
phenol  mixture  (five  per  cent.)  warm,  and  when  the  lancet  was 
plunged  deeply  under  the  nail,  to  his  surprise  the  patient 
uttered  no  cry  nor  manifested  any  demonstrative  indications  of 
pain.  The  patient  assured  him  that  the  pain  had  ceased  like 
magic  when  the  finger  was  immersed  in  the  warm  mentho- 
phenol  mixture.  The  finger  was  dressed  with  gauze,  rendered 
antiseptic  with  two  per  cent,  of  mentho-phenol,  and  healed  in 
a  few  days. 

"  In  a  case  of  suppurative  otitis  media  et  interna,  accompanied 
with  great  pain  and  throbbing,  an  offensive  purulent  discharge 
created  an  eczematous  eruption  in  the  vicinity  of  the  outer  ear. 
The  frequent  syringing  of  the  auditory  canal  with  very  warm 
water,  mixed  with  mentho-phenol,  soon  checked  the  suppura- 
tive inflammatory  process,  and  resulted  in  the  disappearance  of 
the  eczema.  In  another  case,  in  which  a  small  insect  had 
crawled  into  the  ear  of  a  lady,  a  warm  mixture  of  two  per  cent. 


452  ARTIFICIAL    ANESTHESIA. 

of  mentho- phenol  produced  the  insect,  to  the  great  satisfaction 
of  the  patient.  Wounds — incised,  punctured,  lacerated,  etc. — 
will  heal  kindly  when  cleansed  with  warm  water,  mixed  with 
two  per  cent,  of  mentho-phenol.  In  dental  practice,  mentho- 
phenol  finds  its  indications  as  an  anodyne  anaesthetic  in 
odontalgia,  obtunding  the  sensitiveness  of  dentine,  and  as  an 
antiseptic  in  alveolar  abscess,  suppurating  pulps  of  teeth, 
periodontitis,  etc. 

' '  He  has  used  the  medicament  in  pustular  acne.  The  pustules 
may  be  opened  without  causing  much  pain,  after  having  been 
first  touched  with  vaseline  containing  five  per  cent,  of  meniho- 
phenol.  Mixed  with  almond  oil  or  alcohol,  in  the  proportion 
of  two  per  cent,  of  the  medicament,  I  have  used  it  as  an  external 
application  in  itching  of  the  skin.  I  have  never  used  it  sub- 
cutaneously  nor  by  the  mouth.  Mentho-phenol,  like  every 
other  remedy,  has  its  natural  limitations  of  employment.  It 
cannot,  for  instance,  be  used  in  ophthalmological  practice  on 
account  of  the  unpleasant  burning  which  follows  its  use  when 
applied  to  the  conjunctiva." 

Resorcin-Caniplior. 

"This  liquid  is  obtained  by  heating  equal  parts  of  resorcin  and 
camphor.  Its  indications  are  the  same  as  those  of  thymol- 
camphor.  It  is  superior  to  the  mercurial  ointment  in  the 
removal  of  pediculi.  My  chief  object  in  writing  this  article  was 
for  the  purpose  of  directing  the  attention  of  those  interested  in 
medical  chemistry  to  the  large  number  of  chemical  compounds 
which  can  be  produced  when  the  difi'erent  camphors  are  united 
with  the  phenols  and  their  congeners.  The  close  chemical 
relationship  of  these  substances  naturally  leads  one  to  infer  a 
-correspondingly  intimate  physiological  affinity." 

Antipyrine  as  a  Local  Ansestlietic. 

In  Vienna  it  has  already  been  found  necessary  to  forbid  the 
sale  of  antipyrine  except  under  doctors'  prescriptions,  as  no  less 
than  seventeen  deaths  were  attributed  to  stoppage  of  the  heart's 
action,  owing  to  overdoses.  The  freedom  with  which  the 
prescription  of  this  remedy  (antipyrine)  has  been   assumed  by 


ANTIPYRINE    AS    A    LOCAL    ANESTHETIC.  453 

the  public  has  long  since  been  viewed  with  anxiety  bj^  the 
medical  profession,  and  frequent  warnings  have  alreadj^  fallen 
upon  deaf  ears ;  and  j'et  it  is  to  be  feared  that  if  the  epidemic 
of  influenza  should  spread,  manj^  more  examples  of  recklessness 
will  have  to  be  recorded. 

Hypodermic  injection  of  antipyrine  has  been  strongly  recom- 
mended for  the  relief  of  pain  by  See  and  others.  See  considers 
that  it  rivals  morphine  in  the  extent  of  its  action,  that  it  has 
not  the  unpleasant  after-effects  of  that  drug,  and  that  it  does 
not  interfere  with  nutrition  or  lead  to  a  "  craving. ' '  Berdach 
has  lately  been  experimenting  with  the  drug  in  this  way  at 
Prof.  Bamberger's  clinic  at  Vienna.  He  uses  a  fifty  per  cent, 
solution  in  distilled  water,  and  has  experienced  nothing  but 
favorable  results.  All  kinds  of  painful  conditions  were  so 
treated,  the  injection  being  made  at  the  most  painful  spot.  For 
a  few  seconds  after  administration  there  is  a  local  pain  and 
burning  •,  but  this  soon  passes  off,  and  is  followed  by  analgesia 
over  an  area  of  more  than  a  centimetre  round  the  point  of 
injection.  Frankel  and  others  had  previously  noted  this.  The 
most  important  point  inBerdach's  observations  is,  that  the  pain 
is  relieved  in  a  few  seconds  after  the  injection,  the  relief  lasting 
for  at  least  six  hours.  No  disagreeable  effects,  such  as  vomiting, 
sweating,  rash  on  the  skin,  or  depression  of  the  heart  or  pulse 
were  noticed,  and  in  those  patients  who  were  febrile  the  tem- 
perature remained  uninfluenced.  This  is  too  favorable  an 
account,  and  we  cannot  indorse  these  statements,  and  would 
advise  caution  in  its  use.  It  is  also  valuable  in  chronic  catarrh 
in  the  form  of  spray,  dissolved  in  hot  water,  from  10  to  40 
grains  to  the  ounce.  At  times  we  commence  with  solution  of 
cocaine,  then  followed  by  antipyrine,  or  the  two  combined — 2J 
parts  of  cocaine  and  8  parte  of  antipyrine  to  100  parts  of  water 
— and  last,  by  pure  vaseline  in  pharyngeal  irritation  involving 
the  nose  and  Eustachian  tubes,  with  deafness. 


454  ARTIFICIAL    ANESTHESIA. 


CHAPTER    XXL 

Local  Ansesthetics — Oil  of  Eucalyptus,  Ether,  Ehigolene,  Methyl  and 
its  Chloride,  Hydrastine,  Homatropine  and  Ephedrine,  Brucine, 
Apomorphiue,  Erythrophleine,  Caffeine,  Helleboriue,  Canadol, 
Menthol,  Iodoform,  lodol,  Bromide  of  Ethyl,  Bromide  of  Potas- 
sium, Carbolic  Acid,  Quinine,  Antifibrin,  Tymol,  Urethane,  Tri- 
onal  and  Tritronal,  Naphthalene,  Sulphoual,  Pyoktauin  and 
Trichloracetic,  Aristol,  Euphorine,  Hypnal,  Exalgen. 

Having  given  briefly  the  most  important  results  of  the  recent 
observations  and  experiments  -with  cocaine  and  eucaine,  I  now 
pass  to  the  second  part  of  our  subject,  the  older  local  anaes- 
thetics. 

Oil  of  Eucalyptus. 

This  agent  is  recommended  as  a  local  anaesthetic  in  dental 
operations  and  toothache.  Apply  one  drop  or  more  on  cotton 
to  the  sensitive  dentine  just  before  excavating  for  filling. 
The  vinegar  and  oil  in  the  form  of  emulsion  is  a  powerful  and 
useful  liniment  for  neuralgia,  etc.  The  oil  has  also  decided 
antiperiodic  powers,  as  well  as  being  one  of  the  best  stimulat- 
ing expectorants  in  acute  and  chronic  bronchitis.  From  one- 
half  to  one  drachm  a  day  may  be  given  in  divided  doses  in 
capsules  or  mucilage. 

Etlier  as  a  Local  Anaesthetic. 

This  apparatus,  Plate  55,  and  the  various  modifications,  are 
employed  for  local  anaesthesia,  and  j)roduces  so  much  cold  by 
atomizing  the  ether  and  other  volatile  agents  that  it  freezes  the 
skin  and  even  the  deeper  tissues.  It  was  first  used  by  Dr.  B. 
W.  Richardson,  of  London.  It  consists  of  the  elastic  bulb  D, 
which,  with  its  valves,  serves  to  force  air  into  the  elastic  cham- 
ber C,  which,  alternately  expanding  and  contracting,  supplies 
a  steady  stream  of  air  to  the  atomizing  tubes  A,  which  are  of 
metal,  one  branch  of  which  dips  into  the  bottle  B,  containing 


LOCAL    ANAESTHETICS RHTGOLENE    IN    SPRAY.       455 

the  ether,  and  the  inner  tube  for  deHverinif?  tlie  ether  runs  up- 
wards to  the  extremity  of  the  outer  tube.  The  ether  must  be 
directed  on  the  surface,  and  must  be  the  strongest,  therefore 
free  from  alcohol  and  water.  When  the  parts  are  properly 
frozen,  they  become  pale,  shrunken  and  tallowy-looking,  and, 
when  cut,  like  frozen  fat. 

When  the  rubber  bag  D  is  compressed  by  the  hand,  the  reser- 
voir bulb  is  filled,  and  a  double  current  of  air  is  produced ;  one 

Plate  55. 


current  descending  and  pressing  upon  the  ether,  forcing  it  along 
the  inner  tube,  and  the  other  ascending  through  the  outer  tube, 
and  playing  upon  the  column  of  ether  as  it  passes  from  the 
inner  tube.  The  ether  which  is  used  in  England  for  producing 
local  anaesthesia  is  a  mixture  of  amyl  hydrate  and  anhydrous 
ether;  it  has  a  low  boiling-point  and  specific  gravity,  and  is 
dangerous  when  inhaled.  The  best  form  of  ether  to  employ  for 
local  anaesthesia  is  the  anhydrous,  which  is  almost  free  from 
alcohol  and  water,  and  gives  the  best  results. 

liocal  Angesthetics.— Rhig'olene  in  Spray. 

Khigolene. — This  is  one  of  the  most  volatile  of  liquids,  and 
is  obtained  by  the  distillation  of  petroleum.    Its  specific  gravity 


466  ARTIFICIAL    ANESTHESIA. 

is  0.625,  and  it  will  boil  in  the  hand.     It  was  first  introduced  by 
Dr.  Bigelow,  of  Boston. 

A  superficial  layer  of  the  skin  has  been  successfully  frozen  by 
rhigolene.  Not  only  on  the  skin,  but  Dr.  Jarvis  and  others 
have  used  it  in  inter-nasal  surgery  by  means  of  an  atomizing 
apparatus,  which  will  freeze  the  tissues  in  less  than  one  minute. 
Cartilage  and  mucous  membrane  can,  when  thus  frozen,  be 
deeply  and  freely  divided  without  much  pain  or  haemorrhage. 

Drs.  Edes,  Dana  and  Jacobi  had  used  rhigolene  spray  with 
benefit  in  the  treatment  of  neuralgia  ;  but  it  has  been  found 
objectionable,  because  of  the  intense  degree  of  cold  produced, 
and  also  because  it  could  not  be  applied  to  a  sufficiently  large 
space.* 

In  cases  requiring  extensive  operative  interference,  cocaine 
has  been  partially  utilized  in  conjunction  with  the  rhigolene. 

At  one  time  rhigolene  was  considered  very  explosive ;  this  is 
not  the  case  unless  mixed  with  air,  and  brought  near  to  an  open 
light,  or  the  incandescent  cautery. 

Dr.  Richardson,  of  London,  has  found  rhigolene  to  dissolve 
camphor  and  spermaceti,  which  solution,  applied  with  cotton 
and  wool,  he  found  an  excellent  dressing  to  burns.  This  same 
fluid  would  also  dissolve  iodine,  and  was  valuable  in  diseases  of 
the  respiratory  tract  by  inhalation.  The  strength  of  the  iodine 
solution  which  he  uses  is  five  grains  to  a  fluid  ounce  of  rhigo- 
lene. 

Methyl. 

This  is  another  new  local  anaesthetic,  so  stated,  but  obtained 
from  an  old  agent,  namely,  methyl  alcohol.  This  is  the  alcohol 
obtained  from  wood  spirit,  and  much  employed  in  England,  but 
not  in  this  country.  The  new  agent  is  stated  to  be  neutral, 
volatile,  with  an  ethereal  odor  and  pungent  taste. 

The  subcutaneous  injection  of  methyl  induces  more  or  less 
anaesthesia,  but  it  is  of  short  duration.  (  Vrafch,  No.  X.,  1887, 
Bull  Gen.  de  Therap.,  July  15,  1887,  and  Amer.  Jour.  Med. 
Sci,  October,  1887,  p.  527.) 

*-  New  York  Medical  Journal,  July  31,  1887. 


HYDRASTIS    CANADENSIS    AND    HYDRASTINE.       457 

Chloride  of  Methyl. 

Dr.  Jacobi  has  found  the  chloride  of  methyl  an  analgesic  or 
local  anaesthetic,  which  did  not  aifect  the  general  condition  of 
the  patient,  and  that  it  was  invaluable  in  the  treatment  of  neu- 
ralgia, for  the  immediate  relief  of  severe  pain.  It  was  used  in 
the  form  of  spray  under  high  pressure.  The  objection  was  the 
expense  of  the  apparatus  and  the  difficulties  of  getting  the 
drug  (pure). 

(See  Med.  and  Surg.  Reporter,  vol.  Ivii.,  July  2,  1878,  our 
observations  on  this  drug,  and  its  analogy  to  chloroform  as 
usually  obtained ;  see  also  p.  207. ) 

From  his  experience  in  the  use  of  condensed  carbolic  acid,  his 
conclusions  were  that,  in  the  absence  of  chloride  of  methyl,  it 
was  able  to  take  the  place  of  that  remedy  in  sciatica. 

Hydrastis  Canadensis  (Golden  Seal)  and  Hydrastine. 

The  white  alkaloid  contained  in  Hydrastis  canadensis  (Grolden 
Seal).  Experiment  shows  that  it  is  to  this  alkaloid,  rather 
than  its  more  obtrusive  neighbor,  berberine  (j^ellow  alkaloid), 
that  the  valuable  properties  of  Golden  Seal  are  due.  Its  phys- 
iological action,  as  determined  by  experiment  on  the  lower 
animals,  is  briefly  as  follows  : 

' '  In  small  doses  it  elevates  and  in  large  doses  it  depresses  the 
blood-pressure  ;  that  in  small  doses  it  produces  contraction,  and 
in  large  doses  dilatation  of  the  vascular  walls  ;  that  in  the  period 
of  elevated  blood-pressure  it  inhibits  cardiac  action  ;  that  in 
small  doses  it  produces  anaemia  and  in  large  doses  hypersemia 
of  the  alimentary  surface  ;  that  it  induces  uterine  contractions  ; 
that  it  enhances  the  irritability  of  the  motor  and  depresses  that 
of  the  sensory  nerves  ;  and  that  it  exercises  its  control  over  all 
these  organs  through  a  central,  and  not  through  a  peripheral 
influence." 

Experiments  on  man  confirm  the  preceding.  It  dilates 
slightly  the  pupil  of  the  eye,  and  as  a  local  anaesthetic  has 
value,  though  its  action  is  not  so  marked  as  that  of  cocaine  or 
brucine  applied  locally,  or  theine  injected  hypodermically. 
Hydrastine  is  most  applicable  in  catarrhal  states  of  the  stomach, 

30 


458  ARTIFICIAL    ANESTHESIA. 

bowels,  eye,  ear,  nose  and  throat,  though  it  is  indicated  in 
many  other  diseased  conditions.  Amongst  the  diseases  for 
which  it  has  been  found  a  valuable  topical  application  may  be 
mentioned  hyperidosis,  seborrhoea,  acne,  eczema,  ulcers,  gonor- 
rhoea, certain  forms  of  gleet,  various  forms  of  conjunctivitis, 
and  in  the  ear  to  arrest  or  modify  irritating  catarrhal  and  puru- 
lent discharges.  Its  effects  of  contracting  the  uterus  so  power- 
fully may  be  of  special  value  in  obstetrics,  and  its  marked  action 
on  the  spinal  nervous  system  indicates  it  as  a  valuable  tonic  to 
this  portion  of  the  body.  Probably  hydrastine  possesses  much 
of  the  therapy  internally,  as  well  as  externally,  of  the  drug  from 
which  it  is  obtained,  such  as  being  indicated  in  dyspepsia,  con- 
stipation, haemorrhoids,  jaundice  and  other  functional  disorders 
of  the  liver,  etc. 

Dose,  xV  to  i  grain. 

Mr.  1.  N.  Bredin  found  the  following  formula,  used  as  an 
injection  four  times  daily,  gives  beneficial  results  in  gonorrhoea 
and  leucorrhoea,  when  every  other  treatment,  local  and  internal, 
failed : 

IJ»     Hydrastin,     .         .         .         .        ;         .         •  5j. 

Sol.  morphise  (B.  P.), 5ij. 

Mucil.  acacise,  ad,         .        .         ,        .        ,  f  Siv.      M. 
SiG. — Use  as  au  injection  four  times  daily. 

Care  should  be  taken  to  distinguish  the  resinoid  of  the  eclec- 
tics, hydrastin,  which  consists  chiefly  of  hydrochlorate  of  ber- 
berine,  from  the  crystalline  alkaloid  hydrastine  (hydrastina). 

Honiatropine. 

Discovered  by  Landenburg.  It  is  a  derivative  of  tropeine, 
which  latter  is  produced  by  heating  tropine  gently,  in  contact 
with  organic  acids,  and  dilute  hydrochloric  acid.  Tropine  is  a 
derivative  of  hyoscyamine,  also  of  atropine.  Merck  has  suc- 
ceeded in  crystallizing  it  in  transparent  colorless  prisms.  The 
most  useful  salt  has  been  shown  to  be  the  hydrobromate,  which 
is  crystallizable  and  not  hygroscopic.  Its  action  is  similar  to 
that  of  atropine,  being  mydriatic,  narcotic,  sedative  and  anaes- 


BRUCINE.  459 

thetic.  The  dilatation  of  the  \m\n\  takes  place  verj'  energetic- 
ally with  honiatropine,  the  action  beginning  in  from  fifteen  to 
twenty  minutes,  and  reaching  its  height  after  from  sixty  to 
seventy  minutes  ;  while  the  recovery  takes  place  in  a  compara- 
tively short  time,  usually  from  six  to  ten  hours.  It  is  generally 
indicated  in  the  same  complications  as  atropine  and  other  alka- 
loids of  this  class. 

Chlorohydrate  of  Ephedi'iiie. 

Tweedy  and  Ringer  have  proved  by  experimentation  that 
horn  atropine  acts  upon  the  heart  in  the  same  way  as  atropia, 
but  is  much  milder  and  safer.  Dr.  Frommuler  prefers  homa- 
tropine  to  atropine  for  checking  the  night  sweats  of  phthisis. 
He  also  found  it  an  immediate  and  certain  antidote  to  pilocar- 
pin.     Dose,  -J  to  ^  of  a  grain. 

Homatropine  has  been  employed  in  a  large  number  of  cases 
in  this  city,  of  the  strength  of  eight  grains  to  the  ounce  of  dis- 
tilled water,  with  the  Tuio^  of  bichloride  of  mercury.  The 
instillations  have  been  made  every  hour  until  full  dilatation 
takes  place,  and  with  satisfactory  results,  passing  away  soon, 
unless,  as  will  sometimes  happen,  the  druggist  substitutes  atro- 
pine, not  having  the  homatropine  on  hand. 

The  chlorohydrate  of  ephedrine  is  a  new  mydriatic  alkaloid 
obtained  from  Ephedra  vulgaris  by  M.  Kinnossuke  Menra.  It 
should  be  employed  in  a  solution  ten  times  more  concentrated 
than  homatropine,  but  it  is  much  less  costly.  It  does  not  para- 
l^^ze  the  accommodation  for  near  vision. 

Hydrobroinate  of  Homatropine. 

(C16H21NO3HB.     Soluble  in  ten  parts  of  water.) 
A  careful  study  of  the  action  of  hydrobromate  of  homatro- 
pine by  Eisley  and  Jackson  has  proved  to  them  that  this  drug 
is  entirely  satisfactory  for  the  correction  of  anomalies  of  refrac- 
tion, and  is  an  efficient  and  reliable  mydriatic. 

Bruclne. 

Dr.  Mays,  of  this  city,  introduced  pure  brucine  as  a  local 
anaesthetic,  and  kindly  furnished  us  with  a  solution  in  oleic 


460  ARTIFICIAL    ANESTHESIA. 

acid.  We  made  a  number  of  careful  experiments  with  it,  and 
found  it  had  some  slight  anaesthetic  properties,  but  with  the 
objection  that  when  used  freely  on  a  mucous  membrane  or 
abraded  surface  it  produced  some  of  the  symptoms  of  strychnia 
poisoning.  It  is  true,  it  is  less  powerful,  and  eliminated  more 
rapidly  than  strychnia,  but  it  has  this  one  serious  objection.  The 
old  idea  was  that  the  effect  of  brucine,  in  producing  convulsions, 
was  said  to  depend  on  admixture  with  strychnia,  but  Dr.  L. 
Brunton  found  that  pure  brucine  would  produce  convulsions 
and  death  in  rabbits  when  injected  subcutaneously. 

Aponiorpliiae  Hydrocliloras. 

The  objection  to  apomorphia  is  that  it  causes  very  profuse 
secretions  from  the  mucous  membranes.  It  also  acts  as  a  poison 
on  the  muscular  fibre  of  the  ventricle  of  the  heart,  like  an  acid, 
when  employed  internally.  Yet  there  are  ophthalmic  surgeons 
of  this  city  who  use  it  with  success,  applying  it  every  ten  or  fif- 
teen minutes  to  the  eye,  one  drop  at  a  time. 

Erytliroplileine,  or  Haya. 

(The  Active  Principle  of  Erythrophlceum  Guineense.) 

From  a  most  interesting  paper,  read  a  month  ago  (January  11, 
1888),  before  the  Medical  Society  of  Berlin,  by  Dr.  Lewein,  we 
extract  the  following  concerning  a  drug  that  promises  much  : 

"The  hydrochloride  of  erythrophleine  (made  by  E.  Merck, 
of  Darmstadt)  is  readily  soluble  in  water.  A  two  per  cent,  solu- 
tion in  a  dog's  eye  renders  it  insensible  for  from  ten  to  twenty- 
four  hours.  This  solution  is  much  stronger  than  need  he  for 
anaesthetic  uses,  as  will  be  seen  as  we  proceed,  for  Dr.  Lewein 
states  that  '  solutions  of  the  strength  of  one-fourth  or  one-tenth 
or  one-twentieth  of  one  per  cent,  produce  anaesthesia  of  the 
cornea  and  conjunctiva,  continuing  for  from  several  hours  up 
to  two  days,  and  gradually  increasing  in  intensity  during  that 
time.'  The  action  is  altogether  local,  and  if  a  solution  of  it  be 
injected  into  the  eyelid  of  an  animal,  it  becomes  so  insensible 
that  touch  does  not  induce  motion,  while  the  eye  itself  retains 
perfectly  its  sensibility. 


IIELLEBORINE.  461 

"To  give  an  idea  of  the  powerful  action  of  this  substance: 
If  we  make  a  solution  of  the  proportion  of  ^  gramme  to  100 
grammes  of  water,  i.e.,  ^V  gramme  to  2000  drops  of  water  (ap- 
proximately f  of  a  grain  to  one  fluid  ounce  or  a  solution  of 
about  yf^  of  one  per  cent.),  and  of  this  inject  three  full  drops 
into  the  eye,  full  anesthesia  is  produced  (by  0.00015  grammes 
erythrophleine  hydrochloride)  (or  twenty-three  ten-thousandths 
of  a  grain).  If  from  0.0005  grammes  to  0.0015  grammes  of  this 
solution  be  injected  into  a  guinea-pig,  such  an  insensibility  is 
produced  in  the  injected  part,  that  one  can  cut  these  otherwise 
so  sensitive  animals  deeply,  down  to  the  muscles,  without  ob- 
serving any  symptom  of  pain." 

According  to  "  Karewski,"  Medical  Press,  March  4,  1888, 
complete  anaesthesia  was  never  obtained,  but  its  action  was 
much  heightened  by  the  local  production  of  anaemia.  Its  action 
was  not  uniform  in  all  cases.  Subcutaneous  injection  of  at  least 
^3-  of  a  grain  was  necessary  to  produce  analgesia. 

The  after-effects  were  very  disagreeable,  amongst  them 
violent  pain  at  the  point  of  insertion,  coming  on  in  a  few 
minutes  afterwards,  and  becoming  intolerable,  lasting  several 
days. 

Caflfeina — Caffeine . 

A  crystalline  principle  occurring  in  tea  and  coffee.  Various 
trials  of  caffeine  have  not  been  satisfactory  as  a  powerful  local 
anaesthetic.  It  is  valuable  in  slight  operations,  but  much  infe- 
rior to  cocaine. 

Theine,  which  chemically  is  the  same  as  caffeine,  has  also 
slight  anaesthetic  properties.  They  are  both  most  valuable 
diuretics.  The  citrate  of  caffeine  in  five-grain  doses,  alone  or 
in  conjunction  with  antipjTine,  is  a  useful  remedy  in  congestive 
headaches. 

HeUeborine. 

The  helleborus  niger  contains  two  active  principles,  hellebo- 
rine  and  helleborin.  Both  of  the  substances  are  glucosides. 
The  first  has  been  employed  as  a  local  anaesthetic.  Internally 
they  are  both  narcotics  and  active  cardiac  poisons. 


462  ARTIFICIAL    ANESTHESIA. 

Canadol. 

This  is  a  volatile  product  obtained  from  naptha.  Liquid^ 
limpid,  very  volatile,  easily  inflammable,  benzoine  odor.  It 
has  been  used  as  a  substitute  for  ether  as  a  local  anaesthetic^ 
and  is  employed  by  means  of  Richardson's  spray  apparatus. 

Meutliol. 

Has  been  found  very  useful  as  a  rubefacient,  and  combined 
with  some  hypnotic,  it  has  anaesthetic  properties.  It  is  useful 
combined  with  cocaine. 

Menthol  is  an  oil  of  peppermint  camphor;  is  employed  in 
diseases  of  the  throat  and  ear,  dissolved  in  ether  or  olive  oil 
from  ten  to  fifty  per  cent.  It  is  a  great  pain  reliever  when  the 
crystals  are  sprinkled  on  an  aconite  plaster  and  slightly  incor- 
porated by  the  aid  of  heat. 

Iodoform.     (CHI2,  392-8. ) 

Iodoform  is  employed  as  a  local  anaesthetic  and  antiseptic, 
as  a  dressing  after  operations.  Preparation  :  Mix  an  alcoholic 
solution  of  potash  with  tincture  of  iodine,  and  evaporate  it. 
Character:  Small,  lemon-yellow,  lustrous  crystals  of  the  hexag- 
onal system,  having  a  saffron-like  and  disagreeable  odor,  very 
difficult  to  overcome,  and  unpleasant  iodine-like  taste.  Not 
perceptibly  soluble  in  water,  soluble  in  eighty  parts  of  alcohol 
at  59°  F. ,  in  five  parts  of  ether,  and  in  chloroform,  benzol,  ben- 
zine, and  in  the  fixed  and  volatile  oils,  lard,  lanolin  or  vaseline. 
Dose,  1-3  grains. 

It  is  given  in  the  form  of  a  pill  or  in  a  capsule,  or  mixed  with 
tragacanth,  sugar  of  milk  and  glycerine,  or  better,  sugar-coated ;. 
by  the  rectum  in  the  form  of  a  suppository  or  vaginal  capsule. 
The  disagreeable  smell  may  be  in  part  covered  by  Tonquin  bean, 
coumarin ,  or  roasted  coffee  in  powder. 

As  an  inhalation  in  phthisis  a  solution  may  be  used  contain- 
ing 20  grains  of  iodoform,  20  minims  of  oil  of  eucalyptus,  or  10 
of  creasote,  i  fl.  oz.  rectified  spirit,  and  }  fl.  oz.  ether.  This  is 
used  with  an  inhaler  of  horse-hair  matting,  lined  with  cotton 
wool,  on  the  interior  of  which  the  solution  is  droDped .  (Dresch- 
feld.) 


DEODORIZED    IODOFORM    AND    OINTMENT.  463 

As  an  external  application  it  is  dusted  over  the  abraded  skin, 
ulcer,  or  mucous  membrane.  An  old  favorite  preparation  for 
topical  application  is  the  ethereal  solution  of  iodoform  (.^i.  5v.) 
applied  with  absorbent  cotton  to  the  affected  parts  in  the  nares, 
post-pharjmgeal  space,  mouth,  fauces,  larynx  and  trachea. 
The  nozzle  of  the  spray-producer  is  apt  to  become  choked,  and 
must  be  washed  out  frequently  with  pure  ether.  It  may  also 
be  applied  to  the  nose  in  the  form  of  a  bougie,  containing  i  to  ^ 
grain  made  with  gelatine  and  glycerine. 

Actions:  Iodoform  destroys  bacilli,  and  is  an  antiseptic  deo- 
dorizer and  local  anaesthetic.  It  also  destroys  leucocytes.  If 
given  in  large  doses  it  weakens  the  circulation,  or  if  long  con- 
tinued in  moderate  doses,  it  has  the  same  action.  If  absorbed 
from  a  large  raw  surface  or  employed  too  freely,  it  produces 
muscular  rigidity,  anaesthesia,  sleep  followed  by  sleeplessness, 
headache,  irritability,  hallucinations,  loss  of  memory,  melan- 
cholia, and  even  death.  These  disagreeable  effects  are  dimin- 
ished by  bicarbonate  of  potash,  10-grain  doses  every  hour  or 
two,  in  water. 

It  has  a  most  extraordinary  power  to  prevent  the  develop- 
ment of  giant  cells,  and  may  thus  prevent  the  growth  of  mor- 
bid tissue,  as  cancer,  etc.  After  death  from  iodoform,  the 
heart,  liver,  kidnej^s  and  muscles  exhibit  fatty  degeneration. 

Iodoform. 

(Cotton  Wick.) 

Gersung.  of  Vienna,  has  found  cotton  wick  impregnated  with 
iodoform  an  excellent  material  for  tampons  in  the  drainage  of 
wounds  whose  secretion  is  moderate  ;  Bellroth's  clinic  wick, 
saturated  with  tannin  and  iodoform,  is  used  with  excellent  re- 
sults. Its  removal  is  much  less  painful  and  inconvenient  than 
thsit  of  g'duze.—Centralblattfilr  Chirurgie,  July  30,  1887. 

Deodorized  Iodoform  and  Ointmeiit. 

Mr.  Louis  G-enois  has  advocated  the  use  of  the  purified 
naphthaline  to  mask  the  odor  of  the  iodoform,  as  follows : 


464  ARTIFICIAL    ANAESTHESIA. 

Purified  naphthaline, 7i  grains. 

Powdered  turmeric, li  grains. 

Iodoform, 91    grains. 

Rub  together  until  thoroughly  mixed. 

Oiiitineiit  Iodoform. 

Deodorized  iodoform  (as  above),        .        .        .    Sij. 

Oil  of  almond, Siss. 

Lanolin, 5vss.  M. 

We  have  tried  this  preparation,  but  the  strong  odor  of  the 
naphthaline  is  one  objection. 

Iodoform  in  Variola. 

Colleville  has  had  excellent  results  in  preventing  severe  scar- 
ring, and  lessening  pain  in  variola  by  the  local  use  of: 

Iodoform, 1  part. 

Vaseline, 20  parts. 

Although  used  freely  in  cases  of  confluent  variola,  no  ill 
effects  were  observed. — Bevue  de  Therapeutic,  November  5, 
1889. 

Iodoform  Deodorized. 

Cantrella,  pharmacist,  Paris,  has  found  of  all  the  ways 
devised  for  hiding  the  odor  of  iodoform,  the  following  combi- 
nation is  the  best : 

Iodoform, gr.  xv. 

Menthol, gr.  I. 

Essence  of  lavender  (of  best  quality),     .        .        gtt.  1. 

In  addition,  the  hands  may  be  washed  in  water  containing  a 
little  lavender  brandy  or  essence.  Cocaine  may  be  added  to  the 
mixture  when  instant  anaesthesia  is  required,  as  follows : 

Iodoform, gr.  xv. 

Cocaine, gr.  f  • 

— Bulletin  General  de  Therapeutic,  Nov.  15,  1887. 


TREATMENT    OF    DIARRHCEA.  465 

For  deodorization  of  hands  or  any  other  part  of  the  body 
impregnated  with  iodoform,  Doux,  in  the  Bulletin  of  the  Phar- 
maceutical Society  of  Bordeaux,  advises,  first,  vigorous  soap- 
ing of  the  hands,  then  washing  them  in  water  to  which  is  added 
tincture  of  iris  (blue  or  white  flag),  when  the  odor  disappears 
completely. 

Increasing-  the  Antiseptic  Powers  of  Chloroform. 

Gr.  de  Ruyter  {Arch.  f.  Kl.  Chirurg. ,  Bd.  xxxy.  ,  Hft.  1)  states 
that  solutions  of  iodoform  in  ether,  chloroform  and  alcohol  have 
greater  antiseptic  properties  than  the  powdered  drug,  owing 
to  the  production  of  free  iodine.  The  following  solution  was 
found  an  excellent  antiseptic,  and  much  superior  to  the  ethereal 
one  : 

Iodoform, 1  part. 

Ether, 2  parts. 

Alcohol,     .        .        .  ' 8  parts. 

The  author  confesses  that  outside  of  the  body  iodoform  has 
little  power  over  the  greater  number  of  disease  germs.  It  has, 
however,  been  shown  that  when  in  contact  with  the  fluids  of 
the  body  the  iodoform  is  decomposed,  and  is  then  capable  of 
acting  on  bacteria. 

An  Antidote  for  Iodoform. 

The  Rep.  de  Farms  states  that  Dr.  Behring  recently  gave  a 
twenty  per  cent,  solution  of  bicarbonate  of  potassium  in  a  case 
of  severe  iodoform  poisoning.  The  best  results  followed  its 
use,  it  seeming  to  act  as  a  direct  antidote  to  iodoform.  Fortu- 
nately, cases  of  iodoform  poisoning  are  rare  ;  so  much  so,  indeed, 
that  they  are  termed  "idiosyncrasies." 

Treatment  of  Diarrhoea  by  Iodoform  and  Charcoal. 

^     Iodoform, .  grs.  ix. 

Ether, 5iiiss. 

Vegetable  charcoal,  finely  powdered, .        .  Siiiss, 

Glycerin, Sxii.  M. 

SiG. — A  teaspoonful  after  each  evacuation. 


466  ARTIFICIAL    ANAESTHESIA. 

The  iodoform  must  be  dissolved  in  the  ether,  and  the  pow- 
dered charcoal  thoroughly  mixed.  After  the  ether  has  evapo- 
rated, the  glycerine  should  be  added. 

On  the  Local  Use  of  Iodoform  in  Ear  Diseases  and 
Dental  Operations. 

The  following  were  the  conclusions  of  our  friend,  the  late  Dr. 
Cassell,  after  using  this  agent  in  the  treatment  of  ear  diseases 
for  some  years : 

"  Iodoform  is  of  service  alone  in  cases  of  ear  disease  in  which 
there  is  a  lesion  of  tissue  (ulceration),  and  notably  in  those  of 
caries  of  the  mastoid,  complicated  with  polypus  granulations. 
After  these  are  removed  the  local  application  of  iodoform,  as  a 
fine,  dry  powder  generally  acts  capitally,  and,  I  may  add,  suc- 
cessfully. It  is  worthy  of  trial  as  an  internal  remedy  in  those 
cases  of  deafness  following  eye  disease,  where  there  are  keratitis 
and  scooped  (Hutchinson's)  teeth,  and  other  outward  signs  of 
hereditary  syphilis  or  tuberculosis. 

"Nerve  Paste. — A  preparation  for  devitalizing  dental 
pulps,  composed  as  follows :  R .  Iodoform  pulv. ,  cocaine  hydro- 
chlorat. ,  aa  gr.  xx.;  menthol  crust.,  gr.  v.;  glycerina,  q.s.  to 
make  a  stiff  paste. 

"Iodoform  has  not  been  much  used  by  the  dental  practi- 
tioner, but  I  think  in  it  we  have  a  remedy  that  exactly  meets 
the  requirements  of  some  cases.  It  possesses  the  alterative 
properties  of  iodine,  without  its  caustic  qualities;  indeed,  it 
is  a  very  soothing  application  to  inflamed  and  irritated  parts. 
It  has  been  used  with  the  happiest  result  in  the  treatment  of 
old  abscesses,  its  alterative  and  anodyne  qualities  rendering  it 
just  the  thing  for  those  cases  in  which,  from  the  ravages  of 
calculus  or  from  abscess,  the  socket  cells  are  involved,  and  that 
peculiarly  annoying  neuralgia  results,  from  which  the  patient 
finds  slow  relief.  In  these  cases  even  the  extraction  of  the 
tooth  does  not  always  bring  the  immunity  sought  for  some  time. 

"To  apply  the  paste,  take  a  ])robe  armed  with  cotton,  and 
take  up  some  of  the  compound  paste,  introduce  it  into  the 
cavity,  or  under  the  gum  and  around  the  roots. 

"  It  can  be  introduced  into  the  crown  and  roots,  to  relieve 


THE    ANTI-BACTERIAL    ACTION    OF    IODOFORM.       467 

neuralgia,  or  to  cure  persistent  abscess.  In  the  treatment  of 
antral  disease  it  is  regarded  as  one  of  the  very  best  remedies. 
Used  as  above  directed,  its  effect  is  ver^^  soothing,  and  it  will 
speedil}"  diffuse  itself,  and  its  influence,  over  the  seat  of  irrita- 
tion. If  some  persons  should  object  to  the  odor,  the  iodol  may 
be  substituted  in  the  place  of  the  iodoform." 

locloforni  Gauze  TainpoDS. 

Iodoform  gauze  tampons  have  been  found  useful  in  rectal 
disease.  They  are  stated  to  be  painless  and  antiseptic.  The 
mode  of  preparation  of  the  iodoform  gauze  is  given  by  Dr. 
Weir,  as  follows  ("Antiseptics:  How  Used  and  How  Made," 
Med.  News,  December  17,  1887)  : 

Pour  over  five  yards  of  absorbent  gauze  a  mixture  of 

Iodoform, Siiiss. 

Eesiu,  .         . Siss. 

Alcohol, foiv. 

Glycerine, f5vi.    M. 

The  Ajiti-Bactei*ial  Action  of  locloforni. 

In  an  article  by  I.  Amory  Jeffries,  M.D. ,  of  Boston  {Amer. 
Jour.  Med.  Sci.,  January,  1887),  he  states  that  iodol  and  salol 
gave  prompt  results  of  anti-bacterial  action,  but  iodoform,  he 
concludes,  from  numerous  experiments,  has  no  direct  action 
as  a  germicide,  a  result  agreeing  with  Heyn  and  Roosing. 
Looked  at  from  the  clinical  side,  the  ultimate  object  of  all  medi- 
cal research,  he  gives  the  following  rules: 

1.  Iodoform,  not  being  a  germicide,  is  not  a  fit  substance  to 
use  to  procure  asepsis  of  instruments,  materials  or  wounds. 

2.  Iodoform  is  allowable,  in  the  present  state  of  our  pharma- 
copoeia, in  inflicted  wounds  where  the  true  germicides  are  contra- 
indicated,  as  by  danger  of  poisoning  or  impracticability, 

3.  As  has  long  been  known,  iodoform  has  a  decided  tendency 
to  stop  serous  oozing,  and  therefore  may  be  indicated  in  wounds 
where  the  moisture  threatens  the  integrity  of  the  aseptic  or 
antiseptic  dressing.  Laboratory  tests  are  not .  always  what 
occurs  in  the  body,  and  different  observers  produce  different 


468  ARTIFICIAL    ANAESTHESIA. 

results.  Dr.  Robert  T.  Weir,  of  New  York,  with  his  friend,  Dr. 
Weeks,  has  published  in  Med.  News.,  December  17,  1887,  the 
following  observations  on  antiseptics  :  Iodoform  in  powder  only 
retarded  development  of  germs  after  twelve  hours'  exposure, 
lodol  in  powder  exerted  no  effect.  Whoever  has  kept  abreast 
with  the  current  literature  will  not  be  surprised  at  two  things  : 
First,  that  the  fact  taught  us  several  years  ago  by  Koch  has 
been  confirmed  by  Dr.  Weeks,  that  only  solutions  or  mixtures 
of  the  various  antiseptics  have  no  value  other  than  is  slowly 
exerted  by  the  fatty  matters  themselves;  and,  second,  that 
iodoform — concerning  the  power  of  which  in  germs  much  has 
lately  been  written — exerts  its  germicide  action  but  slowly.  On 
this  point  of  the  value  of  iodoform  in  controlling  inflammation 
— ordinary  and  tuberculous — Dr.  Weir  says  that  the  clinical 
experience  of  surgeons  is  in  favor  of  its  usefulness,  and  is 
decidedly  opposed  to  the  laboratory  deductions.  The  discus- 
sion of  this  subject,  however,  has  developed  the  fact  that  this 
substance,  in  dry  powder,  often  contains  germs,  and  that  it 
works  best  when  acted  upon  and  changed  by  wound  secretions. 
Practically,  it  is  nearly  always  used  in  a  dampened  condition, 
by  him,  in  the  New  York  Hospital,  in  conjunction  with  the 
moist  sublimate  gauze.  In  this  combination  it  is  depended 
upon  as  a  supporter  of  antiseptics. 

lodol. 

"lodol  (CINH)  is  produced  by  the  action  of  iodine  on  pyrol 
in  the  presence  of  caustic  potash.  It  has  an  acid  reaction,  is 
free  from  the  disagreeable  odor  of  iodoform,  and  contains  88.9 
per  cent,  of  iodine.  It  is  a  yellowish-brown  powder,  insoluble 
in  water,  slightly  soluble  in  cold  alcohol,  and  readily  soluble 
in  oil.  According  to  Mazzoni,  it  is  a  more  powerful  antiseptic 
than  iodoform  ;  it  acts  as  a  local  anaesthetic  and  favors  granu- 
lation ;  administered  internally  in  doses  of  two  grains,  it  pro- 
duces no  intestinal  disturbance.  It  may  be  used  in  the  same 
way  as  iodoform. 

"  I  have  been  using  this  agent  in  the  place  of  iodoform.  Very 
many  of  my  patients  object  to  the  odor  of  iodoform  ;  iodol,  being 
odorless,  has  this  great  advantage,  though  its  cost  at  present  is 


lODOL.  469 

much  greater  than  that  of  the  iodoform.  I  have  found  it  as 
useful  as  iodoform  in  ear  and  throat  aifections.  It  has  been 
stated  that  it  is  not  so  valuable  in  intra-uterine  affections  as 
iodoform. 

"Dr.  Assaky,  of  Bucharest,  Roumania,  said  that  wounds 
unite  under  iodol  by  first  intention.  This  union,  however, 
being  the  result  of  various  and  complex  conditions  attending 
operation,  it  is  not  possible  to  attribute  to  iodol  alone  the  ab- 
sence of  suppuration  and  inflammatory  conditions.  In  wounds 
which  gape  and  suppurate,  iodol  is  an  excellent  antiseptic.  It 
rapidly  retards  suppuration,  renders  it  inodorous,  reduces  the 
frequency  of  dressing  and  considerably  hastens  cicatrization.  In 
ulcerating  or  gangrenous  wounds,  iodol  aids  to  resist  the  de- 
structive process,  and  changes  the  wound,  after  a  variable  time, 
to  a  healthy  granulating  condition.  This  action  of  iodol  ex- 
tends itself  to  hard  chancres.  In  case  of  soft  chancres  the 
result  is  variable.  Sometimes  it  transforms  them  into  a  simple 
wound  with  brief  delay  ;  at  others  it  is  insufficient  for  this  pur- 
pose, and  it  becomes  necessary  to  employ  in  addition,  locally, 
antiseptic  lotions.  The  same  is  true  with  reference  to  open 
venereal  buboes  of  the  groin.  The  powdered  iodol  has  this 
advantage  over  iodoform,  that  it  is  free  from  odor  and  is  not 
toxic  in  its  effect. 

"Doses  of  iodol,  of  from  one-sixteenth  of  a  grain  to  three 
grains  daily  produce  no  functional  trouble,  even  if  continued 
a  long  time.  These  doses  give  marvellous  results  in  tertiary 
syphilis  and  in  scrofulous  affections.  In  the  secondary  stage  of 
syphilis,  taken  internally,  it  rapidly  destroys  the  syphilitic  mani- 
festations. Iodol  seems  to  aid  the  general  nutrition  and  increase 
strength  and  flesh.  It  is  indicated  in  all  cases  of  specific  malnu- 
trition. Iodol  is  an  antipyretic.  In  acute  infectious  diseases, 
such  as  erysipelas,  etc.,  it  causes  a  rapid  fall  of  temperature. 

"  (1)  Powder  of  Iodol. — The  pure  powder  maybe  used ;  it 
is  readily  dusted  over  a  raw  surface  or  insufflated  into  the 
throat.  Possessing  no  toxic  power,  it  is  of  more  importance  to 
cover  the  diseased  surface  than  to  measure  the  dose.  For  all 
laryngeal,  pharyngeal,  post-nasal  and  oral  conditions,  this  is, 
perhaps,  the  most  generally  useful  application. 


470  ARTIFICIAL    ANESTHESIA. 

"  (2)  A  Solution  in  Alcohol  and  G-lycerine. — This  was 
Mazzoni's  original  application  :  lodol,  one  part ;  alcohol,  six- 
teen parts ;  glycerine,  thirt3^-four  parts.  This  forms  a  good  ap- 
plication by  means  of  the  brush,  or  may  be  used  as  a  very 
coarse  spray. 

"(3)  loDOL,  One  Drachm;  Ether,  One  Ounce.— This 
forms  a  clear  brown  solution,  useful  for  application  either  by  the 
spray  or  brush.  The  ether,  quickly  evaporating,  leaves  the  pow- 
der in  situ.    It  is  useful  for  naso-pharyngeal  atrophic  conditions. 

"  (4)  Iodol,One  Drachm  ;  Glycerine,  One  Drachm  ;  Vas- 
eline, Seven  Drachms. — This  is  a  modification  of  one  of 
Rumbold's  sprays.  It  is  a  very  soothing  application  for  pharyn- 
geal conditions.     It  requires  to  be  warm  before  using. 

"(5)  loDOL  Pastilles. — lodol,  one  grain;  glycerine,  one 
minim  ;  glycogelatine,  eighteen  grains.  These  are  very  useful 
for  chronic  pharyngeal  conditions,  and  are  much  preferable  to 
iodoform  pastilles. 

"(6)  loDOL  Bougies,  containing  half-grain  of  iodol  in  each. 
These  are  made  for  me,  for  use  in  diseased  nasal  conditions. 

"  (7)  Iodol  Wool,  ten  per  cent.,  for  tampons,  etc. 

"  (8)  Iodol  Gauze  for  dressings. 

"  I  have  used  iodol  in  a  number  of  cases  of  laryngeal  phthisis 
with  very  beneficial  results.  Adopting  Lublinski's  method,  I 
have  applied  it  as  an  insufflation  of  the  pure  powder  in  some 
cases  once  daily,  in  others  three  times  a  week. 

"Ulcerations  in  the  inter-arytenoid  region  have  cleansed  and 
healed  up  completely,  and  the  characteristic  arytenoid  oedema 
has  diminished  under  its  influence.  Tuberculous  ulcerations 
of  the  epiglottis  and  pharynx  have  been  benefited  by  it  and  been 
arrested,  and  the  distressing  pains  on  deglutition  which  accom- 
pany this  condition  are  much  relieved  by  iodol.  In  some 
patients,  to  whom  solid  food  was  entirely  interdicted  by  reason 
of  the  pain  on  swallowing,  deglutition  has  become  compara- 
tively easy  under  daily  laryngeal  insufflations  of  iodol.  If  the 
iodol  is  carefully  and  accurately  applied  over  the  ulcerations,  it 
will  completely  heal  them.  I  have  cases  under  treatment  where 
there  was  originally  extensive  laryngeal  ulceration,  but  at  pres- 
ent all  active  mischief  is  arrested.    Iodol  remarkably  diminishes 


IODOFORM    AND    lODOL.  471 

the  cougli  of  this  cundition.  It  is  not  to  be  supposed,  of  course, 
that  insufflations  of  iodol,  or  of  an}-  other  substance,  will  cure 
extensive  phthisical  disease  of  the  larj^nx,  but  they  will  certainly 
arrest  ulceration,  relieve  pain  and  cough,  and  allow  the  patient 
comparative  comfort.  The  iodol  remains  for  a  long  time  in 
contact  with  an  ulcerated  surface.  Sprays  of  chloride  of  zinc 
(gr.  XXX.  ad  5j.)  have,  in  some  cases,  been  combined  with  the 
iodol  treatment.  For  ozaena,  I  find  that  iodol  tampons  are 
effective  in  arresting  the  foul  smell  of  nasal  caries,  or  for  the 
true  ozaenic  conditions  independent  of  carious  bone. 

"As  a  spray  or  brush  application,  it  is  very  beneficial  for 
naso-pharyngeal  atrophic  catarrhs.  For  the  ordinary  forms  of 
pharyngitis,  accompanied  or  not  with  follicular  disease,  I  find  it 
a  very  serviceable  insufflation,  and  one  which,  moreover,  is  not 
unpleasant  to  the  patient.  The  pastilles  are  also  grateful  in 
these  conditions.  It  is  important  that  the  application  of  iodol, 
as  of  any  other  medicament,  to  the  nasal,  pharyngeal  or  laryn- 
geal mucous  membrane  should  be  preceded  by  thorough  cleans- 
ing of  these  parts  with  the  alkaline  lotion,  so  as  to  insure  the 
bringing  of  the  powder  into  direct  contact  with  the  diseased 
tissue,  and  not  merely  to  lay  it  on  the  surface  of  the  mucus.  I 
have  found  it  produce  excellent  effect  in  extensive  ulcerations 
of  the  inside  of  the  cheek,  dusted  over  the  exposed  surface 
twice  daily.  In  cases  where  there  is  great  pain  the  addition  of 
one-eighth  to  one-quarter  grain  morphine  to  the  iodol  insufflated 
will  be  found  very  advantageous. 

"To  summarize:  iodol  is  odorless  or  nearly  so,  tasteless,  pro- 
duces no  constitutional  effects,  contains  nearly  as  much  iodine 
as  iodoform,  and  parts  with  it  more  readily;  it  is  antiseptic, 
anaesthetic,  a  promoter  of  granulation  and  healing;  arrests 
suppuration  and  deodorizes  foul  secretions.  Possessing  thus 
all  the  virtues  of  iodoform,  it  is  surely  preferable  on  account  of 
its  pleasant  and  slight  odor  and  the  absence  of  taste.  It  does 
not  disturb  the  stomach  as  iodoform  does." — E.  Norris  Wolfen- 
den,  M.D.,  in  the  Practitioner. 

locloforni  and  Iodol. 

Is  iodol  perfectly  safe  given  internally  and  employed  locally? 
The  experiments  of  Marcus  and   Pahl  [Maug.    Dess.    Berlin^ 


472  ARTIFICIAL    ANESTHESIA. 

Ther.  Gazette,  January  16,  1888)  show  that  when  iodol  was  given 
in  sufficient  doses  to  animals  it  caused  emaciation,  albuminous 
urine,  fall  of  temperature,  general  loss  of  muscular  power,  and 
finally  death  from  fatty  degeneration  of  the  liver,  kidney  and 
other  tissues.  In  a  case  published  in  the  Ther.  Gazette  (see 
vol.  xi.,  p.  768),  iodol  caused,  when  used  as  a  surgical  dressing, 
symptoms  of  poisoning.  Still,  it  is  less  poisonous  than  iodo- 
form ,  but  the  post-mortem  appearances  are  the  same.  It  has 
been  found  valuable  in  a  number  of  cases  of  tubercular  laryn- 
gitis, throwing  the  pure  powder  into  the  larynx  once  a  week  ; 
also  in  ozaena  with  good  results,  alone  or  combined  with  creosote 
and  gl3^cerine  and  boracic  acid. 

Iodol  in  Diplitheria. 

In  order  to  test  the  statements  of  Dr.  Mazzoni,  Dr.  L.  L. 
Stembo,  of  Yilna,  tried  ( ' '  Proceedings  of  the  Vilna  Medical 
Society,"  No.  V.,  1887,  p.  114)  the  local  use  of  iodol  in  seven 
cases  of  diphtheria,  two  of  which  were  severe.  The  drug  was 
applied  either  alone,  in  powder,  or  in  the  form  of  a  solution. 
(R.  lodoli.,  9ss.  ;  liq.  vini,  5ss.  ;  glj^cerine,  ^iiiss.)  All  the 
patients  recovered  after  treatment  lasting  from  four  to  six  days. 
The  advantages  claimed  by  Dr.  Stembo  for  iodol  are  its  com- 
plete harmlessness,  its  freedom  from  unpleasant  smell  or  taste, 
the  painlessness  of  its  application,  and  the  absence  of  any 
untoward  or  secondary  effects,  such  as  loss  of  appetite,  nausea, 
vomiting,  etc. — British  MedicalJournal,  April  9,  1888. 

Trousseau  has  found  the  following  formula  useful : 

For  an  ointment : 

Vaseline, Sijss. 

Iodol, gr.  30  to  60. 

In  solution : 

Iodol, 3  parts. 

Alcohol, 35  parts. 

Glycerine, 62  parts. 

In  disease  of  the  ducts,  as  the  lachrymal,  etc.,  the  following 
was  found  useful : 


BROMIDE  OF  POTASSIUM  AS  A  LOCAL  ANESTHETIC.       473 

Liquid  vaseline, Sviiss. 

lodol, gr.  xlv. 

{Revue  Gen.  de  Clin,  et  Ther.,  December  29,  1887;  Med. 
News,  January  28,  1888.) 

Mazzoni,  who  first  proposed  the  use  of  iodol  in  practical 
medicine,  employed  a  solution  composed  of  iodol,  one  part; 
alcohol,  sixteen  parts  ;  and  glycerine,  thirty-four  parts. 

The  dose  of  iodol  is  from  two  to  three  grains  a  day,  but  both 
Pick  and  xlssaky  have  given  as  high  as  thirty  grains  a  day 
without  injury.  Pick  asserts  that  iodol  is  absorbed  much  less 
freely  than  iodoform,  requiring  from  twelve  to  eighteen  hours 
for  the  full  elimination  of  the  iodine  in  the  urine  when  tested 
by  a  solution  of  starch. 

Dr.  Harlan,  of  Chicago,  uses  iodol  in  combination  with  pure 
terebene,  as  a  topical  application  to  lacerated  edges  of  the  gums 
after  the  removal  of  necrosed  bone.  It  has  been  also  found 
beneficial  in  the  treatment  of  pyorrhoea  alveolus.  Combined 
with  oleum  gaultheriae,  it  forms  an  excellent  antiseptic  in  de- 
strojnng  the  odors  in  the  cavities  of  diseased  teeth,  and  control- 
ling pain.  Iodol  and  the  other  substitutes  for  iodoform  have 
not,  as  yet,  taken  its  place;  it  is  still  employed  most  exten- 
sively both  in  surgery  and  general  medicine  with  success. 

Bromide  of  Ethyl  as  a  Local  Anaestlietlc. 

The  bromide  of  ethyl  has  advantages  as  a  local  anaesthetic,  a 
pleasant  odor,  not  inflammable,  and  has  been  used  in  France 
and  this  country  with  good  results  (see  pp.  227  to  238).  The 
ordinary  atomizer  produces  a  satisfactory  spray  with  the  bro- 
mide of  ethyl,  ether  and  rhigolene. 

Bromide  of  Potassium  as   a  Local  Anaesthetic  for 
the  Geuito-L^i-inary  Apparatus. 

Bromide  of  potassium  has  long  been  used  as  a  local  applica- 
tion to  the  throat  and  larynx  to  diminish  sensibility.  Acting 
upon  this  suggestion,  J.  Kijanizyer  (St.  Petersburg  Med. 
Wochenschr.,  No.  51,  IS79— Medical  Record)  applies  it  in  a 
similar  manner  and  with  similar  eflPects  to  the  gen  i  to -urinary 

31 


474  ARTIFICIAL    ANAESTHESIA. 

apparatus.  He  injects  a  solution  of  salt  into  the  urethra,  when 
the  latter  is  the  seat  of  painful,  acute  or  chronic  inflammation 
in  strictures,  and  in  cases  of  frequent  pollutions.  In  urethritis, 
he  says,  that  the  pain,  redness  and  tumefaction  of  the  mucous 
membrane  decreased  rapidly,  the  discharge  diminished,  and 
soon  disappeared  entirely  with  the  aid  of  mild  astringents.  In 
a  case  of  stricture,  with  chronic  urethritis  and  painful  micturi- 
tion, where  the  urethra  was  extremely  sensitive,  and  the  severe 
pain  prevented  the  introduction  of  bougies,  in  spite  of  the  use 
oP  cannabis  indica  and  belladonna  salve,  a  bougie  was  introduced 
with  scarcely  any  pain  after  the  use  of  bromide  of  potassium 
injections  for  seven  days.  Kijanizyer  uses  eight  grammes  of 
potassium  bromide  dissolved  in  180  grammes  of  water.  Four 
grammes  of  the  fluid  are  injected  two  or  three  times  a  day,  and 
the  fluid  retained  in  the  urethra  a  few  minutes.  From  his  ob- 
servations he  concludes  that  the  injections  are  of  decided  use,  in 
all  cases  where  the  indication  is  to  diminish  sensibifity  in  the 
urethra  and  neck  of  the  bladder;  in  the  treatment  of  strictures 
with  bougies,  in  inflammations  of  the  urethra  and  their  compli- 
cations; in  chordee,  dysuria,  neurosis,  etc.,  and  for  pollutions 
depending  upon  peripheral  causes.  He  also  recommends  the 
local  use  of  the  salt,  as  indicated  in  catarrh  of  the  bladder  and 
of  its  neck,  in  increased  sensibility  of  the  latter,  and  for  cystic 
calculi  and  the  like.  He  considers  the  eff"ects  to  be  due  to  the 
diminished  irritation  and  lessened  quantity  of  blood  in  the  in- 
flamed tissue. 

Ethyl  Iodide. 

This  agent  has  been  found  useful  as  a  local  anaesthetic,  and 
anti-spasmodic  in  hay-fever  and  cold  in  the  head.  It  is  most 
effectively  applied  by  means  of  glass  capsules  broken  in  a  hand- 
kerchief, and  then  inhaled  from  it,  covering  the  face.  Another 
method  is  by  means  of  a  half-filled  glass  bottle,  which  is  inclosed 
in  the  hand,  the  heat  vaporizing  the  liquid. 

Chloral  and  Camphor  as  a  Local  Angesthetic. 

Equal  parts  of  chloral  and  camj^hor  were  recommended  years 
ago  by  Dr.  Fordyce  Barker  to  stop  the  secretion  of  milk,  and 


PIPER  METHYSTICUM  AND  THE  COCAINE  MOLECULE.      475 

now  we  note  from  the  Canada  Med.  and  Surg.  Jour.,  March, 
1885,  that  before  the  Medico-Chirurgical  Society  of  Montreal, 
Dr.  Lapthorn  Smith  read  a  paper  on  the  use  of  a  mixture  of 
about  equal  parts  of  chloral  hydrate  and  camphor  as  a  local  an- 
icsthetic.     He  stated  that  when  placed  in  the  solid  form  to- 
gether in  a  bottle  they  soon  produced  a  clear,  thick  liquid, 
which,  when  applied  on  a  piece  of  lint,  covered  with  oil-silk,  to 
a  painful   surface,   complete  analgesia  resulted.     He  reported 
three  cases  in  which  he  tried  it  with  good  success.     The  first 
was  a  whitlow  of  the  finger,  which  the  patient  refused  to  have 
opened.     Shortly  after  applying  it  the  pain  disappeared,  and 
three  days  later  it  was  lanced,  and  the  pus  let  out  without  the 
patient,  a  young  lady,  experiencing  any  pain  whatever.     The 
second  case  was  a  very  painful  bubo,  which  completely  disabled 
the  patient,  a  gentleman,  from  doing  his  work.     The  mixture 
of  chloral  hydrate  and  camphor  was  applied  frequently  on  a 
piece  of  lint,  with  the  result  that  a  few  hours  after  the  first  ap- 
plication he  was  so  much  relieved  that  he  returned  to  his  duties 
next  day,  and  fluctuation  becoming  evident  a  few  days  later,  it 
was  opened,  the  operation  causing  only  about  a  quarter  of  the 
usual  amount  of  pain.     The  third  case  was  an  operation  for  the 
removal  of  a  large  sebaceous  cyst  of  the  face,  which  was  accom- 
pHshed  after  the  frequent  application  of  the  local  anaesthetic 
for  several  hours  previously  by  means  of  a  brush.     The  incision 
in  the  skin  was  almost  painless,  but  it  produced  no  efi'ect  upon 
the  deeper  structures  to  which  the  cyst  was  firmly  adherent. 
The  action  of  the  anaesthetic  is  much  less  marked  on  healthy 
than  on  inflamed  and  painful  skin. 

Piper  Methysticum  and  tlie  Cocaine  Molecule. 

Filehn  remarks  {Berl  Klin.  Woch.,  vii.,  1887),  that  for  a 
time  cocaine  seemed  to  stand  alone  in  its  local  anesthetic  action. 
Then  a  similar  property  was  found  to  belong  to  the  resin  from 
piper  methysticum  (Kava).  All  the  ordinary  alkaloids  have 
been  tested  in  reference  to  this  point  by  Bergmeester  and  E. 
Ludwig,  with  negative  results.  Searching  after  a  substitute, 
Filehn  directed  his  attention  to  the  chemical  constitution  of  the 
cocaine  molecule.     Just  as  atropine  can  be  split  up  into  and  re- 


476  ARTIFICIAL    ANESTHESIA. 

constituted  from  tropic  and  acid  tropin,  so  cocaine  can  be  re- 
solved by  heat  into  benzoic  acid,  methyl  alcohol  and  ecgonine. 

Carbolic  Acid.  * 

Carbolic  Acid  {carbo  and  oZewwi  "  oil  "). — Carbolic  acid, 
impure  [acidum  carhoUcum)^  a  liquid  obtained  from  coal-tar 
oil  hy  treatinoj  it  first  with  an  alkali,  then  with  an  acid,  and 
finally  distilling  it.  It  is  of  a  brownish  shade,  becoming  reddish 
brown  on  exposure.  It  consists  of  carbolic  acid  and  cresylic 
acid,  with  impurities  derived  from  the  coal-tar. 

This  form  is  only  used  externally,  or  for  disinfecting  pur- 
poses, and,  at  the  iron  works,  mixed  with  oil  for  relieving  burns. 

Pure  Carbolic  Acid  {acidum  carboJicum  purificatum). — 
When  pure,  and  while  it  is  in  crystals  or  liquid,  it  is  also 
termed  phenic  acid,  or  phenol.  Its  odor  and  taste  is  like 
creosote,  fusible  at  from  93  to  104,  forming  an  oily  liquid, 
soluble  in  from  20  to  33  parts  of  water,  and  in  alcohol, 
ether,  glycerine,  and  the  essential  oils.  Carbolic  acid,  if  ap- 
plied to  the  skin,  produces  pain  and  local  anaesthesia,  so 
that  the  actual  cautery  and  other  irritating  substances  can  be 
applied,  or  incision  made  with  comparative  impunity.  In 
the  form  of  sHghtly  carbolized  oil,  it  is  most  valuable  in  burns 
over  a  large  area  of  skin,  yet  care  must  be  observed  for  fear  of 
absorption,  if  there  is  much  loss  of  the  skin.  It  is  also  used  in 
treating  surgical  diseases  by  hypodermic  injections,  as  hydro- 
cele and  haemorrhoids.  Carbohc  acid  prevents  or  corrects  putre- 
faction in  cases  of  purulent  infection,  dissecting  wounds,  hos- 
pital gangrene,  and  parasitical  diseases  of  the  skin,  as  scabies, 
prurigo,  thrush.  Internally  it  may  be  given  in  doses  of  from 
J  grain  to  2  grains,  in  a  tablespoonful  of  some  bland  liquid, 
every  hour,  in  cases  of  yeasty  vomiting,  flatulence,  dependent 
on  fermentation  in  undigested  food.  Its  salts,  as  the  carbolate 
of  soda,  of  potash,  zinc,  have  been  used  externally  for  local 
application  and  for  disinfecting  purposes  ;  also  in  various  aque- 
ous, alcoholic  and  ethereal  solutions,  and  in  the  form  of  liniment 
and  ointments. 

It  has  been  ascertained  that  if  animals,  to  whom  carbolic 
acid  had  been  previously  administered,  are  treated  by  soda  sul- 


CARBOLIC    ACID.  477 

phate.  a  harmless  compound  of  phenol  and  sulphuric  acid  is 
formed.  Thus  it  has  been  found  that  the  symptoms  of  carbolic 
acid  i)oisoning  are  relieved  by  the  free  use  of  this  agent.  If 
this,  or  even  the  common  Grlauber  salt,  is  given  when  the  urine 
becomes  dark-colored,  it  will  arrest  the  toxic  phenomena  from 
slow  poisoning.  In  these  sudden  cases,  when  the  carbolic  acid 
is  swallowed  in  such  large  quantities,  it  has  been  advised  to 
resort  to  zinc  sulphate,  sulphate  of  magnesia,  Epsom  salts,  or 
any  sulphate.  After  the  evacuation  of  the  stomach,  the  free 
use  of  lime-water  and  olive  or  linseed  oil  is  useful  to  soothe  the 
burnt  mucous  membrane,  and  when  this  is  not  at  hand  resort 
to  flour  starch,  eggs  or  milk  with  warm  water.  While  a  resident 
physician  at  the  Philadelphia  Hospital  a  fatal  case  of  poisoning 
took  place  from  swallowing  the  ordinary  liquid  acid,  which  is  of 
a  brown  color,  resembling  brandy ;  the  individual  mistaking  it 
for  that  agent,  swallowed  it.  Collapse  followed,  and  death  was 
almost  immediate.  Several  similar  cases  have  occurred  since. 
The  seventh  case  occurred  at  Liverpool  quite  recently,  the  acid 
being  mistaken  for  spirits,  as  reported  in  a  Glasgow  newspaper 
while  we  were  on  a  visit  to  that  city.  In  the  first  case  which 
we  had  the  opportunity  of  seeing  a  post-mortem  was  made,  and 
the  tissues,  from  the  throat  to  the  rectum,  were  of  a  brown 
color,  and  changed  to  a  leather-like  consistency,  while  the  urine 
and  other  secretions  were  black. 

Carbolic  acid  has  produced  poisoning  both  by  its  local  appli- 
cation and  by  being  swallowed.  Children  and  delicate  women 
have  been  the  sufferers  from  its  free  local  application.  It  pro- 
duces a  species  of  intoxication.  The  symptoms  are,  in  the  case 
of  adults,  nausea,  vomiting  and  headache ;  but  in  children  the 
symptoms  are  more  severe,  the  temperature  falling  below  nor- 
mal, the  pulse  being  extremely  weak,  and  the  body  covered  with 
a  cold  sweat. 

Fatality  in  a  Belfast  Hospital.— A  patient  in  Belfast 
Hospital,  named  James  Jeffers,  was  accidentally  poisoned  in 
that  institution,  through  taking  a  draught  of  carbolic  acid, 
which  the  nurse  in  the  ward  in  which  he  was  located  gave  him 
in  mistake  for  a  black  draught.  x\fter  drinking  a  portion  of 
the  stuff,  Jeffers  remarked,  "You  have  given  me  the  wrong 


478  ARTIFICIAL    ANESTHESIA. 

medicine,"  and  fell  back  insensible.  The  nurse  having  discov- 
ered the  mistake,  by  testing  the  liquid,  rushed  wildly  for  the 
house  physician,  who  was  promptly  in  attendance.  Antidotes 
were  administered,  but  the  man  died  an  hour  afterwards.  Miss 
Torrens,  who  was  taken  seriously  ill  shortly  after  tasting  the 
poison,  was  placed  under  arrest.  She  was  not  aware  of  the 
death  of  the  patient,  and  the  doctors  considered  it  would  be 
injudicious  to  inform  her  of  the  fact.  The  affair  created  quite 
a  sensation  in  Belfast,  where  Miss  Torrens'  friends  move  in  the 
best  society. 

Another. — Another  death  from  carbolic  acid  poisoning — the 
eighth  in  a  few  weeks — occurred  at  Liverpool,  a  woman  drinking 
the  poison  in  mistake,  as  usual,  for  spirits. 

Quinine  an  Antipyretic  and  Anaesthetic. 

The  first  and  best  known  of  the  agents  is  the  active  principle 
of  cinchona,  or  quinia,  and  its  various  salts,  but  chiefly  the  sul- 
phate, which  is  now  so  extensively  employed.  This  valuable 
medical  agent,  some  twenty  years  ago,  was  most  employed  by 
Fenner,  of  New  Orleans,  and  in  enormous  doses  as  a  sedative 
in  all  kinds  of  fever  ;  but  it  was  found  that  in  many  instances 
it  depressed  the  nervous  system  and  acted  most  injuriously  upon 
the  patient — so  that  at  the  present  day  it  is  no  longer  emploj^ed 
in  such  poisonous  doses.  Soon  after  the  Grermans  took  up 
this  same  drug  and  described  it  as  an  antipyretic,  and  with  it 
endeavored  to  reduce  the  temperature  of  all  fevers,  especially 
that  of  typhoid.  In  thus  endeavoring  to  cure  the  disease  by 
the  simple  reduction  of  temperature,  the}^  did  not  eff"ect  a  cure, 
but  frequently  the  immense  doses  of  quinine  acted  upon  the 
nervous  system  and  as  an  anaesthetic,  and  caused  the  death  of 
the  patient. 

At  the  present  day  it  is  resorted  to  chiefly  as  an  antiseptic  to 
combat  or  destroy  the  various  forms  of  bacteria,  or  micrococci, 
and  diseases  of  a  remittent  or  intermittent  type.  To  obviate 
its  injurious  effects  upon  the  nervous  system  it  should  be 
combined  with  the  bromides  or  hydrobromic  acid,  or  extract  of 
ergot. 


LOCAL  ANAESTHETICS,  ANALGESICS  AND  HYPNOTICS.      479 


JLocal  Aiiji^sthetics,  Analgesics  and  Hypnotics. 

^'Thymol,  the  product  of  the  fractional  distillation  of  the  vol- 
atile oil  of  thyme,  obtained  from  the  plant  thj'mus  vulgaris, 
has  long  been  used  as  a  substitute  for  carbolic  acid,  in  its  varied 
applications,  with  the  great  advantage  of  having  a  less  disagree- 
able odor,  and  causing  no  pain,  as  it  is  not  irritating. 

"  It  has  recently  found  a  new  use  in  the  treatment  of  chyluria 
dependent  upon  filaria  in  the  blood.  As  a  remedy  for  this 
affection  has  long  been  sought,  the  favorable  report  of  Surgeon- 
Major  E.  Lawrie,  of  Hyderabad,  of  a  cure  of  two  cases  is 
worth  noting.  The  important  practical  point  noticed  was  that 
thymol  destroyed  the  organisms  present  in  the  system.  Reason- 
ing a  priori,  Dr.  Lawrie  tried  it  extensively  in  diseases  such  as 
leprosy,  phthisis  and  gonorrhoea,  but  without  success.  His 
conclusions  then  are  that  either  thymol,  acting  evidently  as  a 
fatal  poison  to  the  filaria,  is  not  a  poison  to  the  bacillus,  whicli 
seemed  to  him  very  unlikely,  or  else  the  bacilli  are  not  the 
cause  of  the  diseases  above  mentioned.  Other  cases  are  now 
necessary  to  corroborate  Dr.  Lawrie' s  good  results."  (Dr. 
Squibb's  Epliemeri,<<,  vol.  iii.,  No.  6,  p.  L311.) 

Dr.  Hartmann  [Deutsche  Med.  Wochenschrift)  has  employed 
thymol  in  toothache  from  cavities,  in  place  of  arsenious  acid. 
He  fills  the  cavity  of  the  tooth  with  a  tuft  of  cotton  on  which 
thymol  has  been  sprinkled.  It  does  not  irritate  the  mucous 
membrane  of  the  mouth  much,  and  it  is  easily  removed  by  rins- 
ing the  mouth  with  water.  If  a  rapid  action  is  desired  let  the 
patient  rinse  the  mouth  often  with  warm  water,  in  order  to 
facilitate  the  solution  of  the  drug.  It  never  increases  the  pain 
at  first,  as  arsenic  does,  and  is  not  poisonous. — Lancet- Clinic. 

"SuLPHONAL  is  one  of  the  usually  safe  (but  uncertain)  hyp- 
notics which  has  had  very  wide  use,  and  has  largely  increased 
during  the  past  year.  Two  of  its  properties  of  great  merit  are 
its  odorlessness  and  almost  tastelessness.  (The  usual  dose  is 
from  ten  to  fifteen  grains  suspended  in  hot  water.)  Its  effect 
has  been  noticed  to  last  over  to  a  second  and  third  night ;  and 
if  this  peculiarity  is  noted,  it  has  its  evident  advantages  as  well 
as  disadvantaees.     Italian  observers  have  mentioned  favorable 


480  ARTIFICIAL    ANAESTHESIA. 

results  in  diabetes.  It  diminishes  the  quantity  of  sugar,  the 
polyuria,  and  the  thirst.  They  also  have  noticed  its  good  effects 
in  either  greatly  diminishing,  or  entirely  suppressing,  the  night- 
sweats  in  phthisis.  Dr.  D.  D.  Stewart,  of  Philadelphia,  recom- 
mends it  to  be  taken  thoroughly  dissolved  in  as  hot  an  aque- 
ous solution  as  agreeable.  Sleep  is  then  induced  very  soon  after 
taking,  and  thus  is  avoided  the  usual  delay  of  an  hour  or  more 
before  the  effect  is  ordinarily  produced.  Dr.  AY.  H.  Gilbert,  of 
Baden-Baden,  reports  danger  from  its  popular  and  steady  use. 
It  is  surely  bad  practice  to  leave  the  matter  in  the  patient's 
hands  to  the  extent  of  directing  him  to  take  a  certain  dose 
whenever  he  cannot  sleep,  as  is  apparently  the  practice  with 
some.  There  are  evidences  now  on  record  of  the  habit  being 
established  approaching  that  of  the  morphine  habit.  Fatal 
cases  also  have  been  reported  during  the  past  year.  For  such 
an  effective  and  widely  used  hypnotic,  then,  the  conclusion 
should  be  to  use  caution." — Ephemeris.  vol.  iii..  No.  6,  p.  1310. 

Sulphonal  (Di-Ethyl-Sulphon-Di-Methyl-Methane)  continues 
to  be  a  very  prominent  agent  in  the  practitioner's  hands, 
although  caution  is  urged  and  generally  exercised. 

"Occasionally  an  eruption  over  the  body  follows  its  use. 
After  a  time  the  urine  is  found  to  be  of  a  dark  color,  which  a 
microscopical  and  clinical  examination  proves  to  be  caused 
by  the  presence  of  haematoporphyrin,  and  in  some  cases 
large  quantities  of  indican.  Experience  with  this  hypnotic 
teaches  us  to  be  very  cautious  in  its  administration,  to  watch 
closely  the  effects  of  the  first  doses  in  a  patient  who  has  not 
previously  taken  it,  and  always  to  discontinue  its  use  when  the 
urine  gets  dark." 

Dr.  Edmund  Andrews,  of  Chicago,  111.,  Professor  of  Clini- 
cal Surgery  in  the  Northwestern  Medical  School,  writes  as 
follows : 

"  I  found,  some  years  ago,  that  it  had  a  singular  antispas- 
modic quality,  and,  in  consequence  of  my  brief  writings  and 
personal  statements  on  that  point,  it  is  considerably  used  in 
Illinois  for  that  effect. 

' '  In  the  painful  muscular  spasms  after  fractures  of  the 
thigh  and  of  some   other  bones,  its   effects  are  surprising  in 


LOCAL  ANAESTHETICS,  ANALGESICS  AND  HYPNOTICS.      481 

eflfectually  suppressing  the  spasms  without  necessarily  inducing 
sleep.  Opiates  will  do  as  long  as  the  patient  keeps  awake, 
but  the  moment  he  drops  asleep  he  is  liable  to  be  aroused 
by  the  spasms.  Sulphonal  suppresses  them  totally  by  night 
or  day,  without  any  reference  to  whether  the  patient  is  asleep 
or  awake. 

"Some  healthy  men  are  troubled  by  cramps  in  the  limbs  at 
night.  Sulphonal  taken  occasionally — sometimes  only  once  a 
week — prevents  them.  The  effect  seems  to  be  very  pro- 
longed. 

'*  Some  cases  of  persistent  hiccough  are  stopped  by  it. 

"  Some  surgeons  use  it  to  arrest  nocturnal  emission  of  semen 
with  striking  effect,  the  action  seeming  to  be  by  arresting  the 
nocturnal  spasms  of  the  ejaculatory  muscular  fibres  that  expel 
the  semen. 

"I  do  not  know  that  any  one  has  tried  it  in  epilepsy  or 
tetanus. 

"Its  hypnotic  and  anodyne  powers  are  feeble. 

"I  have  not  seen  it  produce  any  of  the  alarming  symptoms 
often  described  when  given  in  10-  or  15-grain  doses  for  cramps 
once  in  a  day  or  two,  or  in  8- grain  doses  for  nocturnal  emissions 
given  two  or  three  times  a  day," 

Mr.  J.  A.  Shaw-Mackenzie,  M.R.C.S.,  of  London,  England, 
recommends  this  agent  in  railway  and  sea  sickness.  He  reports 
as  follows  :* 

"Inquiry  elicits  the  fact  that  there  are  many  who  suffer  from 
railwa}^  sickness.  I  am  not  aware  that  direct  attention  has  been 
given  to  this  special  cause  of  megrim  ;  I  am  satisfied,  however, 
that  the  inconvenience  is  real,  and  that  there  are  many  who  are 
more  or  less  affected  by  a  long  journey,  and  in  whom  a  rail- 
way journey  of  two  hours  produces  as  much  dread  and  misery 
as  a  sea  passage.  I  venture  to  draw  attention  to  the  value  of 
sulphonal  in  these  cases,  and  to  suggest  its  further  and  more 
extended  trial  in  both  railway  and  sea  journeys.  In  children, 
train  sickness  is  common,  while  in  adults  railway  megrim  varies 

*  London  Lancet,  vol.  i.,  1395,  p.  1434;  Ephemeris,  voL  iv.,  No. 
1306,  p.  1728. 


482  ARTIFICIAL    ANESTHESIA. 

from  undue  fatigue  and  inability  to  sleep  the  same  night  to  in- 
tense headache,  sickness  and  prostration  coming  on  after  some 
two  hours  in  the  train.  The  dose  of  sulphonal  would  vary,  o^ 
course,  according  to  the  severity  of  the  symptoms  and  the 
length  of  the  journe.y.  In  my  own  case  I  find  that  10  to  15 
grains  are  sujfficient  for  the  day  journey  to  Edinburgh,  while  20 
to  30  grains  in  divided  doses  are  necessary  for  the  night  and  day 
journey  to  the  north  of  Scotland." 

^^ Sulphonal — This  is  a  hypnotic,  valuable  in  insanity  when 
sleep  is  required,  but  there  is  danger  from  it  in  doses  of  3  to  4 
grammes,  and  it  then  becomes  a  poison.  From  the  deep  sleep 
which  it  produces,  if  weak  from  loss  of  blood,  the  patient  is  apt 
not  to  recover.  At  other  times  it  causes  alarming  symptoms  in 
the  intellectual  functions,  disorder  of  the  motor  system  and 
digestive  tract.  The  dose  is  from  5  to  1 5  grains  one  to  three 
hours  before  going  to  bed  ;  better  taken  with  hot  fluid." 

''Pyoktanin  (methyl- violet)  is  the  newly  adopted  trade 
name  given  to  one  of  the  anihne  dyes  long  used  for  staining 
bacilli  and  micro-organisms ;  it  is  now  believed  to  have  a  de- 
structive action  on  these  organisms,  and  it  has  been  put  forth 
as  a  new  antiseptic  and  bactericide.  There  is  another  form 
called  the  yellow.  Each  is  used  for  special  purposes.  The 
former  seems  now  to  be  preferred  in  surgical  operations  gene- 
rally, and  the  latter  in  ophthalmological  in  particular.  Its  pus- 
destroying  property,  from  which  it  derives  its  name,  is  appa- 
rently well  established  at  this  time,  but  it  has  not  shown 
uniformly  good  results  otherwise.  However,  there  are  observers 
now  who  claim  that  it  has  little  effect,  if  any,  on  suppuration, 
and  the  staining  of  the  hands  and  clothes  which  accompany  its 
use  is  strongly  against  it.  This  latter  objection,  however,  has 
been  met  somewhat  by  the  suggestion  that  these  stains  may  be 
removed  by  soap-lather  well  rubbed  in,  and  washing  or  brush- 
ing off  with  alcohol.  It  has  been  employed  in  the  treatment 
of  cystitis  with  some  favorable  results ;  but  in  general  urethral 
injections,  where  much  good  may  follow,  Mr.  F.  F.  Burghard, 
of  King's  College  hospital,  claims  that  too  strong  solutions  are 
recommended.  He  advises  beginning  with  a  solution  not 
stronger  than   1   to  3000,  and  gradually  increasing  up  to  1   to 


LOCAL  ANESTHETICS,  ANALGESICS  AND  HYPNOTICS.      48S 

1500,  otherwise  irritation  and  scalding  on  micturition  occur. 
On  open  wounds  and  ulcers  the  powder  is  simply  dusted  on 
with  good  effect,  and  where  thej'  have  become  septic  this  agent 
is  more  efficacious  than  any  other  antiseptic.  Remarkable  suc- 
cess is  reported  from  abroad  from  its  use  on  malignant 
growths ;  and  even  cancer  has  been  experimented  upon,  both 
here  and  abroad,  with  the  result  of  ameliorating  the  sufferings 
and  of  acting  as  an  effective  deodorizer.  In  the  various  affec- 
tions of  the  eye  very  diverse  reports  are  on  record,  both  in  this 
country  and  abroad.  In  general,  the  majority  acknowledge- 
that  some  good  effects  follow  its  use,  but  it  has  not  yet  arrived 
at  that  surpassing  value  at  which  its  introducer  would  figure 
it." — Ephemeris^  vol.  iii.,  No.  6,  p.  1306. 

"Acid  Trichloracetic  offers  us  another  great  agent  for 
detecting  albumin  in  urine.  It  is  one  of  the  newer  tests,  which 
bids  fair  to  remain  with  us.  It  has  been  used  considerably 
since  it  was  first  brought  forward,  and  with  success.  Insurance 
examiners  are  the  loudest  in  praising  it.  It  may  be  used  in  the 
form  of  a  saturated  solution,  or  a  crystal  of  the  acid  may  be 
dropped  in  the  suspected  urine.  The  turbid  line,  which  form& 
immediately  at  the  junction  of  the  liquids,  is  to  be  distinguished 
from  that  formed  by  urates  by  the  rapidity  of  formation  of  the 
former. 

"This  acid  has  also  been  found  effectual  as  a  caustic  and 
astringent.  In  throat  and  nose  affections  its  effect  is  much 
more  local  than  some  of  the  other  caustics.  It  is  readily  solu- 
ble in  water,  and  deliquesces  easily.  Out  of  140  cases  treated 
by  one  practitioner,  87  needed  but  one  application.  Dr.  J.  W. 
Gleitzmann,  of  tliis  association,  has  met  with  very  favorable 
results,  and  summarizes  as  follows:  '1.  Trichloracetic  acid 
compares  favorably  with  other  caustics  in  hypertrophic  condi- 
tions of  the  throat  and  nose,  and  is  a  valuable  addition  to  the 
remedies  now  in  use.  2.  In  the  greatest  majority  of  cases  it  i& 
sufficient  to  produce  the  desired  reduction  of  tissue,  although 
it  does  not  supersede  the  galvano-cautery.  3.  It  can  be  applied 
with  safety  to  the  larynx  w^ithout  any  evil  consequences.  4. 
Its  chief  advantage  in  nasal  affections  is  the  drjniess  of  its- 
eschar,  which  prevents  unpleasant  sequelae,  and  makes  after- 
treatment  unnecessary.'  " — Epheineris,  vol.  iii.,  No.  6,  p.  1285. 


484  ARTIFICIAL    ANESTHESIA. 

"Aristol  is  one  of  the  new  antiseptics  brought  forth  as  a 
substitute  for  iodoform.  It  is  a  reddish -brown  powder  made 
by  treating  a  strongly  alkaline  solution  of  thymol  with  iodine. 
It  gradually  becomes  paler  in  color,  due  to  the  iodine  given  ofif 
from  exposure  to  sunlight  and  to  heat.  It  therefore  should  be 
kept  from  an  undue  amount  of  light  or  heat.  It  has  the  dis- 
advantage in  some  respects  of  being  insoluble  in  water.  Owing 
to  its  unstable  nature,  the  excipients  which  may  be  employed 
are  limited.  It  is  used  mostly  in  the  powdered  form,  but  its 
use  "with  olive  oil,  collodion  and  the  ointments  in  general  is 
rapidly  on  the  increase.  For  the  two  previous  years  it  has  been 
mostly  known  by  the  name  of  'annidalin,'  but  recently,  and 
since  the  inauguration  of  new  modes  of  preparation,  it  has 
been  urged  forward  with  renewed  vigor  under  its  present 
name. 

"From  recent  investigation  it  appears  that  its  efficiency  is 
largely  due  to  its  instability,  and  anj"  attempt  to  render  it  free 
from  its  property  of  slowly  giving  off  iodine  renders  it  compar- 
atively inert.  It  has  been  suggested  that  this  very  fact  may 
account  for  some  of  the  failures  which  have  been  reported  by 
some  investigators. 

"Aristol  at  the  present  time  has  universal  testimony  as  to  its 
usefulness  in  medicine.  Some  go  so  far  as  to  claim  that  it  is 
one  of  the  most  important  additions  to  our  materia  medica  in 
recent  years.  Its  antiseptic  power  is  very  pronounced.  It  has 
a  slight,  but  not  unpleasant,  odor.  When  dusted  on  open 
wounds  or  ulcers  it  is  not  irritant,  and  promotes  rapid  cicatriza- 
tion. It  has  no  toxic  effects,  as  iodine  cannot  be  found  in  the 
urine  after  using  in  any  of  its  forms  of  application:  It  is, 
therefore,  a  safe  remedy  to  leave  in  the  hands  of  a  patient,  as 
experience  has  now  proved.  None  of  the  iodoform  substitutes 
have  as  large  a  proportion  of  iodine  as  iodoform  itself,  aristol 
having  less  than  one." 

"Recent  Hypnotics  and  Analgesics. — Urethane— ethyl 
carbonate.  A  decided  antagonist  to  strychnine.  Also  a  hyp- 
notic in  doses  of  30  to  60  grains  ;  but  it  was  noticed  that  a  rapid 
tolerance  of  the  drug  took  place,  and  is  therefore  unreliable. 
iyhloral  Hydrate. — This  is  not  a  certain  hypnotic,  yet  in  doses 


NAPHTHALINE.  485 

of  30  to  45  grains  it  has  been  found  useful.  Occasionally, 
headache,  giddiness  and  nausea  follow  its  administration,  with 
diminished  tension  and  frequency  of  pulse. 

"Trional  and  Tetronal. — Trional  and  tetronal  contain 
three  and  four  ethyl  groups,  and  sulphonal  only  contains  two. 
As  a  hypnotic,  tetronal  was,  in  fourteen  cases,  superior  to  sul- 
phonal, in  six  cases  equal,  and  in  four  inferior.  The  dose  is 
the  same.  In  a  more  recent  report  tetronal  is  said  to  have  all 
the  disadvantages  of  sulphonal  without  its  power,  its  action 
being  more  sedative  than  hypnotic.  Euphomie. — Euphorine 
is  phenyl  urethan,  derived  from  aniline — white  crystalline 
powder.  It  is  an  antiseptic.  Dose,  from  15  to  20  grains  in 
twenty-four  hours  ;  can  be  taken  without  bad  results.  In  a  few 
cases  euphorine  acted  well  as  an  analgesic,  but,  on  the  whole, 
the  success  must  be  considered  small.  According  to  '  Sanso- 
ric,'  in  chronic  ulcers  and  ophthalmia,  the  powder  proved 
itself  a  better  antiseptic  than  any  other  which  the  author  had 
tried. 

'"''Hypnal. — By  heating  antipyrine  with  chloral  hydrate  a  crys- 
talline compound  is  produced  which  is  termed  hypnal,  and  par- 
takes in  a  marked  degree  of  the  properties  of  both.  Dose, 
15  grains.     It  was  found  to  produce  sleep  with  anodyne  effect. 

^''  Exalgin. — Methj^lacetanilid  ;  a  benzine  derivative  allied  to 
phenacetin.  Dose,  J  grain  in  facial  neuralgia,  given  in  rectified 
spirits.  It  was  found  unsuitable  as  an  antipyretic  because,  in 
full  doses,  it  is  apt  to  produce  untoward  symptoms." — Ephe- 
meris,  vol.  iii.,  pp.  1283-1288. 

Kaphtlialine . 

Naphthaline  (CH)  is  the  product  of  the  distillation  of  coal- 
tar,  of  which  it  posseses  the  disagreeable  odor.  It  should  be 
carefully  used  on  account  of  its  irritant  effects  on  the  renal 
tissues,  and  the  peculiar  modifications  in  the  nutrition  of  the 
eye. 

Naphthaline  has  been  found  useful  in  flatulent  dyspepsia  in 
combination  with  a  small  portion  of  morphia. 

Naphthaline  has  been  found  one  of  the  best  agents  for  ex- 
pelling taenia  and  ascarides.     The  dose  for  an  adult  is  15  grains 


486  ARTIFICIAL    ANESTHESIA. 

when  the  stomach  is  empty  (in  capsules),  followed  immediately 
by  two  tablespoonfuis  of  castor  oil.  Children  may  take  4  to  8 
grains,  and  at  the  same  time  a  tablespoonful  of  castor  oil. 
Prior  to  taking  the  dose  the  patient  should  eat  freely  of  salad 
and  green  food. 

Guaiacol  (Mononietliyl-Catecliol ;  Liquid  Methyl 
Ether  of  Protocatechin). 

Obtained  from  beech-wood  creosote  by  fractional  distillation — 
CHgOa  =  C6H,(OH)OCH3— colorless,  limpid,  oily  liquid  ; 
aromatic  odor.  Specific  gravity,  1.33  at  15°  C.  Boils,  201- 
207°  C.  Antiseptic,  antipyretic,  analgesic.  Tasteless,  insolu- 
ble in  water,  slightly  soluble  in  alcohol  and  ether,  sparingly 
soluble  in  glycerine  and  fixed  oils.  It  may  be  given  in  capsules, 
wine  or  oil.  Dose,  five  drops  daily.  Valuable  local  remedy  in 
lupus  and  other  forms  of  external  surgical  tuberculoses.  It  has 
been  found  by  Dr.  William  James  Morton  that  guaiacol  re- 
strains the  action  of  cocaine  to  local  territory  and  prevents  its 
toxic  action.  (See  his  article,  p.  380,  on  Gruaiacol-Cocaine 
Oataphoresis. ) 

Tropacocaine.  — This  alkaloid  was  obtained  from  the  narrow- 
leaved  coca  plant  of  Java.  It  is  in  the  form  of  an  oily  liquid, 
which  solidifies  in  radiating  crystals,  and  is  soluble  in  chloro- 
form, ether  and  benzine.  Dr.  Arthur  P.  Chadbourne  has  found 
its  action  similar  to  cocaine,  and  only  half  as  toxic  as  cocaine. 
In  lower  animals,  in  full  doses  (dose  not  stated),  loss  of  co- 
ordination, followed  by  violent  convulsions,  disturbance  of 
respiration,  coma  and  death  by  centric  asphyxia.  Tropacocaine 
has  been  used  as  a  local  anassthetic  in  the  eye,  it  is  asserted, 
with  good  results.  This  has  not  been  confirmed.  It  acts  more 
quickly  than  cocaine.     It  is  not  a  good  mydriatic. 

Benzol  (benzoin)  CeHg.  A  hydrocarbon  formed  by  the  dry 
distillation  of  organic  substances,  but  chiefiy  derived  from  coal- 
tar.  It  is  inflammable  and  very  volatile,  and  is  an  excellent 
solvent  for  grease.  It  acts  as  a  local  anaesthetic  on  epizoa.  Its 
vapor  is  used  in  whooping-cough. 

"  Chloralamid  (chloral-formamide)  is  the  new  hypnotic  ob- 
tained by  the  combination  of  chloral  and   the   colorless,  oily, 


GUAIACOL.  487 

liquid  formamide — an  organic  compound  allied  to  urea.  Our 
foreign  brethren  are  very  enthusiastic  over  their  results  with  it 
as  a  decided  rival  to  chloral  and  sulphonal.  Its  best  effects  are 
produced  in  cases  of  idiopathic  insomnia,  cases  where  the  in- 
somnia is  not  due  to  either  extreme  pain  or  excitement.  Al- 
though it  may  succeed  in  some  cases  in  overcoming  slight  pains, 
it  cannot  be  classed  as  an  anodyne.  It  induces  a  natural  and 
refreshing  sleep,  and,  as  a  rule,  is  not  followed  by  headache 
on  waking  the  following  morning.  A  sense  of  well-being  is 
the  result  of  the  rest  it  affords.  It  is  thought  by  some  to  be  a 
deeper  sleep  than  that  produced  by  chloral.  There  have  been 
some  failures  to^produce  sleep  with  it,  but  the  per  cent,  of  such 
cases  is  small.  Some  Parisian  and  Grerman  observers  claim  that 
its  action  is  exactly  the  same  as  chloral  hydrate,  if  allowance  be 
made  for  the  smaller  proportion  of  chloral  anhydride  in  the 
chloralamid.  It  was  supposed  that  it  acted  by  decomposing  in 
the  circulation,  liberating  chloral  ;  but  there  does  not  occur  with 
it  the  marked  depression  so  characteristic  of  chloral.  In  the 
majority  of  cases  it  works  well,  but  in  a  small  proportion  there 
are  unusual  effects,  not,  however,  in  greater  proportion  than 
with  morphia  or  chloral.  There  are  no  apparent  cumulative 
effects,  and  no  craving  for  it  is  noticed,  although  it  may  be  given 
nearly  every  twenty-four  hours  for  several  weeks.  Of  late  some 
success  has  been  met  in  cases  of  epilepsy;  but  the  most  satis- 
factory results  have  been  obtained  in  senile  insomnia,  pulmo- 
nary diseases  and  hysteria.  It  appears  to  possess  the  very 
happy  property  of  counteracting  the  desire  to  micturate  at 
night  in  senile  cases.  It  occurs  in  colorless  crystals,  with  a 
mild,  slightly  bitter  taste,  and  without  odor.  It  is  soluble  in 
about  ten  parts  of  cold  water,  and  one  should  be  cautious  not 
to  dissolve  it  in  warm  water,-  nor  to  heat  the  solution  after  it  is 
made,  as  it  very  rapidly  decomposes.  Its  use  in  this  country  is 
rapidly  spreading. " — Epliemeris,  vol.  iii.,  p.  1292. 


PAKT    SEVENTH. 


CHAPTER   XXII. 

Anaesthesia  and  Ansestlietics. 


A  Supplement  for  the  Student  to  Commit  to 
Memory. 

Ansesthesia — the  word  is  derived  from  the  Greek  avaiaew^a, 
want  of  feeling,  or  condition  of  insensibihty,  or  loss  of  feeling 
due  to  a  variety  of  pathological  conditions  of  the  brain  centres. 
The  origin  of  the  phrase  "artificial  anaesthesia  "  is  due  to  Oliver 
Wendell  Holmes.  Anaesthetic,  not  to  feel  a  substance  that 
produces  insensibility  to  feeling  of  pain,  and  causes  muscular 
relaxation.  Anaesthetics  act  in  various  ways,  as  general,  partial 
and  local. 

The  first  systemic  anaesthetic  is  alcohol.  It  is  a  cardiac  stimu- 
lant and  anaesthetic.  It  is  obtained  by  the  distillation  of  fer- 
mented grain,  as  "  Spiritus  Frumenti,"  or  whiskey,  but,  to  be 
pure,  alcohol  must  test  not  less  than  forty  per  cent.  Absolute 
alcohol  is  purified  by  redistillation  and  bone-black  filtration. 
The  symbol  of  alcohol  is  (C2H5HO4),  and  contains  but  nine 
per  cent. ,  by  weight,  of  water. 

JEther  (made  by  the  action  of  sulphuric  acid  on  alcohol)  is 
the  first  and  most  important;  it  is  a  stimulating  anaesthetic. 
Anaesthesia  by  ether  is  divisible  into  two  stages.  The  first  is 
one  of  excitement,  and  the  second  stage  is  evinced  when  the 
conjunctiva  is  insensible  to  the  touch  of  the  finger,  and  muscular 
relaxation  is  complete,  with  slightly  stertorous  breathing. 
During  the  second  stage  there  is  complete  loss  of  consciousness, 
with  perfect  relaxation,  and  when  the  arm  is  lifted  it  falls  at 


ANAESTHESIA    AND    ANAESTHETICS.  489 

once.  The  respiration  is  slow  and  regular.  If  this  anaesthetic 
stage  is  forced,  the  stertorous  breathing  is  increased,  and  there 
is  partial  paralysis  of  the  muscles  of  the  palate,  in  which  event 
it  is  a  good  rule  to  temporaril}'  withdraw  the  anaesthetic  agent. 

Ether,  one  of  the  most  important  of  stimulating  anaesthetics 
(U.  S.  P.).  Specific  gravity,  0.725-0.728  =  64°.  Boils  at  37° 
C.  Ethyl  oxide;  ethylic  or  sulphuric  ether,  should  contain 
ninety-six  per  cent,  ether,  four  per  cent,  alcohol,  traces  of 
water,  CiHioO.  Discovered  in  1540  by  Valerius  Cordus,  who 
gave  it  the  name  of  oleum  vitrioli  dulce.  Frobenus  changed 
the  name  to  ether  in  the  year  1730.  Its  anaesthetic  properties 
were  first  suggested  by  Dr.  Jackson,  of  Boston,  to  W.  T.  Gr. 
Morton,  a  dentist,  who  employed  it  under  the  name  of 
' '  Lethion  ' '  for  extracting  teeth  ;  and  the  first  successful  de- 
monstration in  general  surgery  was  made  by  him  in  the  Massa- 
chusetts General  Hospital,  October  16,  1846,  when  Dr.  John  C. 
Warren  removed  a  tumor  without  any  indication  of  pain. 

Ether  is  produced  by  acting  upon  strong  alcohol*  with  sul- 
phuric acid,  and  heating  the  mixture  to  280°-300°  F.  This 
compound  undergoes  double  decomposition,  ethjd  sulphuric  acid 
and  water  being  first  liberated,  the  ethyl  sulphuric  acid  after- 
wards combining  with  a  molecule  of  alcohol  to  form  ethyl  ether 
and  sulphuric  acid,  thus  : 

Beaction,  C2H5OH  +  H^SO,  =  SO2OHOC2H5  -f  H^O. 
Then,  C2H5OH  +  SO2OHOC2H5-  (C2H5)20  +  H^SO,. 

Formula,  (02115)20  or  C4H10O. 

The  ether  is  purified  by  passing  over  fused  chloride  of  cal- 
cium, which  removes  the  alcohol,  and  is  then  rectified  by  distil- 
lation. The  vapor  is  very  inflammable  and  sinks,  by  its  density, 
to  the  floor.  There  are  sold  three  kinds  of  ether — commercial 
ether,  unfitted  for  anaesthesia,  purified  ether,  and  absolute  ether. 

AD]\nNiSTRATiON. — Ether  as  an  ansesthetic  should  be  given 
cautiously  with  great  gentleness  by  dropping  from  a  bottle 
upon  a  folded  napkin  or  by  means  of  Allis'  inhaler. 

*  Ethyl  hydrate,  absolute  alcohol  (C20H5OH)  of  good  quality  should 
not  contain  more  than  one  per  cent,  of  water. 

32 


490  ARTIFICIAL    ANESTHESIA. 

Cliloroforni. 

Chloroform  was  discovered  as  chloric  ether  by  Guthrie,  in 
America,  and  by  Soubeiran,  in  France,  in  1831,  who  made  it  by 
the  action  of  chloride  of  lime  on  alcohol.  In  1832  chloroform 
was  rediscovered  (chemical  process)  by  Liebig.  By  him  it  was 
produced  as  follows :  Methyl  chloride  and  chlorine  in  vapor 
CH3CH  +  2CI2  =  2HC1  X  CHCI3.  By  this  method  it  was  very 
impure.  Its  impurities,  methodic  compounds,  were  very  com- 
mon, and  can  be  detected  by  the  addition  of  a  few  drops  of 
sulphuric  acid.  If  impure,  this  acid  will  blacken  the  liquid 
(chloroform). 

The  ordinary  process  of  manufacture  is  bj'  the  action  of 
bleaching  powder  upon  alcohol,  and  the  chief  impurities  are 
free  chlorine  gas  and  hydrochloric  acid. 

The  cheaper  process  for  the  manufacture  of  chloroform  is 
termed  the  acetone  process  ;  but  this  "acetone,"  which  is  ob- 
tained from  various  sources,  is  not  always  pure.  The  proper 
agent  to  be  employed  is  alcohol.  Many  of  the  fatalities  are,  no 
doubt,  due  to  the  use  of  this  cheap  variety  of  chloroform. 

A  very  pure  Chloroform  is  now  made  from  Chloral  Hydrate. 

Added  Impurities. — Alcohol  or  ether.  Chloroform  boils  at 
60°  C;  sp.  gr.  1.  A  temperature  of  96°  vaporizes  chloro- 
form if  held  in  the  hand.  It  is  not  inflammable,  but  near  a 
flame  of  gas  decomposes,  separating  into  poisonous  vapors. 
Chloroform  should  be  kept  in  tin  or  dark  amber-colored  bottles, 
and  in  the  dark. 

Specific  gravity  149°  at  15°  C.    Boils  at  60°  C.    Comp.  HCI3. 

A  form  of  stimulating  anaesthetic  mixture  is  composed  of 
alcohol,  ether  and  chloroform,  or  nitrous  oxide  and  oxygen. 
Chloroform  is  a  depressing  angesthetic.  The  principal  general 
or  systemic  anaesthetics  emploj^ed  are  alcohol,  nitrogen  monox- 
ide or  nitrous  oxide,  ether  or  ethjd  oxide  (C4H5O)  (C2H5)0, 
chloroform,  methyl  chloride,  terchloride  of  formjd,  bromide  of 
ethyl  or  hydrobromic  ether. 

Bromide  of  Ethyl,  Hydrobromic  or  Bromic  Ether. — 
CaHjBr.  Specific  gravity  1.4733  ;  boils  at  40.7°  C.  It  is  pre- 
pared by  distilling  alcohol  (ethj^lic)  with  either  bromine,  hydro- 
bromic acid,  or  bromide  of  phosphorus ;  it  is  a  colorless,  trans- 


THE    MOST    PROMINENT    LOCAL    ANESTHETICS.       491 

lucent  liquid,  of  ethereal  smell  and  sweet  taste.  Its  action  upon 
human  beings  is  to  produce  unconsciousness  and  anaesthesia  in 
one  minute  and  partial  relaxation  {occasioncdly  complete)  in 
two  to  three  minutes.  When  given  to  excess  it  kills  b}^  direct 
action  upon  the  respiratorj'  centres.  For  prolonged  operation 
it  is  not  advisable — the  limit  of  time  is  fortj^  minutes.  Impu- 
rities, free  bromine,  carbon,  bromide  phosphorus  and  bromo- 
form.  Should  be  kept  in  sealed  tubes  and  from  both  light  and 
air.  It  should  not  be  emploj-ed  except  for  examinations  and 
in  minor  surgery  and  for  an  occasional  obstetric  case. 

Nitrous  Oxide  G-as. — NgO,  obtained  from  nitrate  of  am- 
monia hj  distillation.  Kt  226°  F.  the  salt  melts  ;  at  460°  F. 
it  gives  oif  gas.  Purified  by  passing  through  solution  of  sul- 
phate of  iron  and  caustic  potash  and  water.  It  is  now  to  be 
had  condensed,  at  a  temperature  of  44.60°  F.  (7°  C),  into  a 
liquid  at  a  pressure  of  fifty  atmospheres,  and  can  be  carried 
about  in  steel  cylinders  for  convenient  use.  If  not  properly 
prepared  the  liquid  gas  may  contain  air. 

The  Most  Proininent  Local  Anaesthetics. 

Cocaine  hydrochlorate. 

Cocaine  cataphoresis  by  electricity. 

Cocaine  benzoate. 

Cocaine  borate. 

Cocaine  carbolate  (cocaine  phenate). 

Camphor  phenique. 

Carbolic  acid. 

Chloral  hydrate. 

Ether  absolute. 

Ethyl  bromide. 

Ethyl  chloride. 

Eucaine  hydrochlorate. 

Guaiacol,  with  cocaine  cataphoresis. 

Ice  (with  chloride  of  sodium). 

Menthol  (peppermint  camphor). 

Methj'l  chloride. 

Salicj'iate  of  sodium. 


492  ARTIFICIAL    ANESTHESIA. 

The  most  important  of  these  local  anaesthetics  is  cocaine,  active 
principle  of  the  erythroxylon  coca.  The  leaves  of  the  plant 
from  which  it  is  obtained  are  employed  as  a  stimulant  and 
sustaining  agent,  when  mixed  with  a  little  lime,  and  are  chewed 
like  tobacco  by  the  Indians  of  Peru  and  South  xlmerica.  When 
making  long  journeys  over  the  mountains  of  South  America 
the  Indians  can,  by  its  use,  go  for  a  long  period  of  time  without 
food.  The  alkaloid  is  prepared  by  maceration  with  lime,  and 
distillation,  and  is  then  dissolved  in  alcohol  for  purification. 

Its  composition  is  C1TH21N1O4.  Its  action  is  first  stimulant, 
then  narcotic.  It  is  a  powerful  local  anaesthetic  on  the  mucous 
memhrane.  When  applied  to  the  eye  it  causes  dryness  of  tis- 
sues, dilatation  of  the  pupil  and  partial  paralysis  of  accommo- 
dation.    Dose,  i"  to  -I  of  a  grain. 

Contra-indkation. — Fatty  degeneration  of  the  heart  and 
atheromatous  disease  of  the  arteries.  Must  be  employed  with 
caution  in  hysterical  individuals  and  epileptics. 

Antidotes. — Amyl  nitrate,  free  use  of  black  cofi'ee,  aromatic 
spirits  of  ammonia,  and  for  the  depression  following,  minute 
doses  of  nitrate  or  sulphate  of  strychnia,  -i^  to  i^  of  a  grain. 

Amount  of  cocaine  used  must  be  in  proportion  to  the  extent 
of  surface  it  is  desired  to  anaesthetize.  In  no  case  should  the 
quantity  exceed  one  grain  and  three-quarters. 

Cocaine  should  never  be  used  in  cases  of  heart  disease,  or  in 
persons  of  highly  nervous  temperament. 

In  injecting  cocaine  the  intradermic  method  is  preferable  to 
hypodermic.  By  injecting  into,  not  under,  mucous  membrane 
or  skin,  the  risk  of  entering  a  blood-vessel  is  avoided.  It  has 
been  found  valuable  to  dissolve  it  in  a  boiled  solution  of  chlo- 
ride of  sodium. 

During  injection  the  patient  should  always  be  in  a  recumbent 
or  semi-recumbent  position  ;  in  operations  upon  the  nose  and 
throat,  or  teeth,  the  head  should  not  be  raised  until  anaesthesia 
is  complete. 

It  is  of  great  importance  that  cocaine  should  be  pure,  since 
its  combinations  with  certain  other  alkalies  result  in  poisonous 
compounds. 

Liebermann    discovered    among    the    amorphous  accessory 


PRECAUTIONS    TO    BE    TAKEX.  493 

bases  of  coca  leaves  an  exceedingly  toxic  substance  :  Isatropyl- 
cocaine,  which,  accordinor  to  Liebreich,  acts  as  a  direct  heart- 
poison.     The  last-named  investigator  speaks  hereof  as  follows  : 

"I  deem  it  quite  probable  that  the  hydrochlorate  of  cocaine, 
unless  it  be  very  perfectly  made,  also  contains  th^  afore-men- 
tioned heart-poison,  even  though  it  be  found  but  in  traces." 

Following  cocaine,  the  next  important  local  anaesthetic  is 
eucaine.  Its  advantages  are.  that  it  is  less  poisonous  than  co- 
caine, but  is  apt  to  produce  more  burning  in  the  eye  than 
cocaine;  but  by  combining  the  two  this  is  obviated. 

Precautlon.s  to  Be  Taken  in  Administration  of 
Cliloroforni,  Ether  and  Xitrou.s  Oxide. 

Chloroform. — In  employing  chloroform  as  an  anassthetic 
note  that  there  is  no  organic  disease  of  the  heart  or  kidneys  ; 
see  that  the  bowels  have  been  moved  ;  but  little  food  must  be 
given  the  day  before  :  commence  with  gentleness  and  care, 
and,  drop  by  drop,  pour  the  liquid  upon  a  towel  or  a  wire  frame 
covered  with  a  flannel.  After  a  minute  or  two  the  strength  is 
increased  so  as  to  get  over  the  stage  of  excitement,  but  do  not 
keep  the  towel  too  near  the  face  of  the  patient.  "Watch  the 
respiration  with  great  care,  and  note  the  pulse  for  fear  of  heart 
depression  in  weak  subjects.    As  a  rule  the  head  should  be  low. 

Judge  of  the  fitness  for  the  operation  by  loss  of  conjunctival 
reflex  by  gently  touching  with  the  finger.  Xote  the  size  of 
pupil  for  sudden  dilatation,  or  as  an  indication  of  heart  depres- 
sion. If  the  patient  vomits,  turn  him  to  one  side,  and  with 
the  fingers  remove  any  solid  food,  and  prevent  its  being  drawn 
back  into  the  larynx  by  a  strong  inspiration. 

It  is  a  well-recognized  maxim  that  chloroform  should  not  be 
administered  in  a  dental  chair,  nor  for  the  removal  of  a  tooth. 

The  color  of  the  patient's  face,  lips  and  ears  is  important,  as 
great  Hvidity,  cyanosis,  and  pallor  are  all  indications  of  danger. 
"Watch  for  dropping  back  of  the  tongue,  dropping  of  the  jaw. 

If  chloroform  must  be  employed  as  the  anaesthetic,  it  is  well 
to  have  it  mixed  with  oxj'gen  gas,  as  it  is  thereby  made  more 
safe. 


494  ARTIFICIAL    ANAESTHESIA. 

Etlier,  What  are  the  Precautions  in  the  Use  of 

Ether  ? 

Commence  just  as  you  would  with  chloroform ;  give  it  in 
small  quantities,  and  do  not  place  patients  on  their  backs  and 
pour  it  down  into  the  mouth,  and  in  this  way  choke  them  in 
the  beginning,  but  use  it  first  by  dropping,  and  then  add  a 
few  drops  of  cologne  water. 

After  the  first  stage  the  towel  or  inhaler  can  be  placed  almost 
in  contact  with  the  mouth,  having  previously  anointed  the  lips 
and  nose  with  vaseline,  in  which  there  is  a  small  quantity  of 
cocaine.     Be  careful  not  to  give  an  excess  of  ether. 

The  etherizer  must  give  his  whole  attention  to  the  patient 
both  before,  during,  and  after  the  operation. 

Anaesthetics  are  rapidly  absorbed,  and  almost  as  rapidly 
eliminated  by  the  skin.  They  are  taken  into  the  blood  and 
reach  every  portion  of  the  system. 

The  action  of  anaesthetics  is  secondly  upon  the  nerve  centres 
controlling  sensation  and  muscular  motion. 

The  symptoms  of  asphyxia  are  developed  in  the  use  of  all 
anaesthetics,  and  are  analogous  but  not  identical  with  true  an- 
aesthesia asphyxia,  which  is  quite  common  with  nitrous  oxide, 
less  with  ether,  and  still  less  with  chloroform.  They  all  pro- 
duce temporary  changes  in  the  blood,  but  do  not  become  per- 
manent, unless  administered  in  poisonous  doses. 

It  has  been  found  that  when  an  animal  or  man  is  killed  by 
ether  or  nitrous  oxide,  the  arterial  blood  gives  only  spectrum 
lines  of  reduced  haemoglobin,  while  after  death  from  chloroform, 
the  lines  of  oxyhaemoglobin  are  very  apparent. 

Dr.  Chalmers  Da  Costa  endeavored  to  show  that  deaths 
under  ether  were  the  same  as  in  chloroform,  but  his  observa- 
tions have  not  been  confirmed. 

Watch  the  respiration.  Remember  that  the  nervous  cen- 
tres regulating  the  act  of  respiration  are  situated  on  the  floor 
of  the  fourth  ventricle.  If  instead  of  normal  respiration  it  is 
stertorous,  as  when  breathing  through  the  nose  and  mouth  at 
the  same  time,  irregular  respiration  is  apt  to  follow,  in  which 
case  the  lips  are  partially  closed,  the  cheeks  distended,  and  the 


BEFORE    GIVING    AX    ANAESTHETIC.  495 

nostrils  dilate  with  each  expiration,  which  is  attended  with  a 
puffing  sound. 

When  the  respiration  becomes  irregular,  look  out ;  for  there  is 
danger  with  the  use  of  the  anaesthetic. 

The  cerebrum  presides  over  the  functions  of  intelligence  and 
volition,  while  co-ordination  and  emotional  impressions  depend 
upon  the  medulla  oblongata  and  cerebellum. 

Resuscitation  is  the  act  of  raising  up  again,  or  the  bringing 
to  life  from  suffocation  or  asphyxiation. 

Asphyxia  is  the  effect  upon  the  body  of  non-oxygenated 
blood,  in  turn  causing  obstruction  of  the  larynx,  which  is  also 
produced  by  food,  blood  or  other  foreign  substances.  It  is 
characterized  by  extreme  lividity  of  countenance,  prominence 
of  eyeball,  and  all  symptoms  of  obstructed  respiration. 

In  artificial  respiration  the  aeration  of  the  blood  is  produced 
by  artificial  means,  by  the  muscles  of  the  chest  which  are 
moved  ;  the  arms  also  act  as  levers  by  compressing  the  chest, 
and  the  elevation  of  them  expands  it.  Place  the  patient  on  one 
side  at  intervals,  so  as  to  give  exit  to  mucus,  blood  or  water,  as 
in  drowning  ;  employ  rhythmic  movement  of  the  chest,  and 
keep  the  tongue  drawn  out.  There  are  some  ten  different 
methods  of  artificial  respiration  practiced,  but  all  depend  upon 
the  principles  we  have  announced.  The  jaw  must  always  be 
forced  forwards,  as  it  is  apt  to  fall  back  :  so  also  the  tongue 
must  be  drawn  out. 

Before  Giving-  an  Aneestlietic. 

"Inquiry  should  be  made  before  giving  the  anaesthetic,  if  the 
patient  has  any  foreign  body  in  the  mouth.  Also,  if  the  patient 
has  ever  taken  an  ansesthetic  before.  The  consent  of  the  patient 
should  in  all  cases  be  obtained,  except  in  that  of  a  child  or  in  a 
case  of  great  emergency.  When  ether  is  first  inhaled,  even  when 
mixed  with  air,  it  is  apt  to  cause  a  feeling  of  oppression  or  suffo- 
cation, which  can  be  overcome  by  encouraging  the  patient  to 
take  a  deep  breath,  and  increasing  the  strength  of  the  vapor. 
Then  there  is  an  interval  of  rest  when  the  patient  almost 
ceases  to  breathe,  followed  by  a  degree  of  excitement,  when  the 


496  ARTIFICIAL    ANESTHESIA. 

patient  is  apt  to  shout,  sing  or  crj',  swear,  or  even  ready, 
when  the  stage  is  passed,  to  fight.  Then  the  patient  becomes 
quiet,  and  passes  into  the  true  ansesthetic  state  or  sleep.  For 
vomiting  after  ether,  apply  mustard  plaster  over  the  epigastrium, 
with  the  use  of  a  grain  of  aeetanilide  every  hour  or  by  rectal  in- 
jections of  bromide  of  sodium  and  laudanum  in  starch-water. 
For  persistent  singultus,  drachm-doses  of  HoiFman's  anodyne 
are  very  effective.  For  vomiting  after  the  use  of  ether  Dr.  Hare 
recommends  the  following  formula  :  1  grain  of  aeetanilide,  1 
grain  monobromated  camphor,  and  1  grain  of  citrated  caffeine, 
given  every  hour  for  six  or  eight  doses. 

"Oxygen  and  Ether. — The  mixture  of  ether  vapor  and 
oxygen  gas  forms  a  highly  explosive  compound.  If  ozonized 
ether  is  conducted  into  anhj'drous  ether,  it  forms  a  thick  liquid 
which  explodes  if  heated.  Chloroform  when  mixed  with  oxy- 
gen undergoes  no  change."     (Hare.) 

Specific  Gravity  of  Ether. 

Specific  gravity  is  the  measured  weight  of  a  substance  com- 
pared with  that  of  an  equal  volume  of  another  taken  as  a 
standard.  For  liquids,  distilled  water  is  the  standard  at  its 
maximum  density.  It  is  found  that  the  specific  gravity  of  ether 
differs  very  much  as  given  by  different  authorities.  On  p.  148, 
the  writer  has  given  it  as  0.750  at  59°  F.,  from  U.  S.  P.  In  a 
recent  work  by  Dr.  Hare  it  is  stated:  "at  77°  F.  the  specific 
gravity  of  ether  should  be  0.714  to  0.717.  The  ether  which  is 
chiefly  employed  in  private  practice  and  also  in  most  of  our 
hospitals  is  that  of  Dr.  Squibb." 

The  writer  requested  the  well-known  pharmaceutical  chemist, 
Mr.  Frank  E.  Morgan,  of  Philadelphia,  to  determine  for  him 
the  specific  gravity  of  this  form  of  ether,  which  he  has  kindly 
done  as  follows : 

"  Squibb' s  Ether  for  Ancesthesia  has  a  specific  gravity  of  .725 
at  59°  F.  Absolute  Ether  has  a  specific  gravity  of  about  .718  at 
the  same  temperature. ' ' 


ELECTRICITY    IN    RESUSCITATION.  497 


Electricity  in  Resuscitation. 

In  applj'ing  this  agent  in  resuscitation  it  must  always  be  borne 
in  mind  that  the  dr^'^  skin  offers  an  enormous  resistance  to  the 
passage  of  the  current,  but  if  the  skin  is  well  wet  with  salt 
water  the  current  will  pass  through  it  with  facilit3\  For  gen- 
eral galvanization,  so  as  to  bring  the  whole  nervous  system 
under  the  influence  of  the  galvanic  current,  one  pole  (usually 
the  negative)  is  placed  at  the  epigastrium,  while  the  other,  or 
positive,  is  passed  over  the  forehead,  or  by  the  inner  border  of 
the  stero-cleido-mastoid  muscle,  from  the  mastoid  fossa  to  the 
sternum  ;  again,  along  the  nape  of  the  neck  to  the  spine.  The 
seance  should  not  be  longer  than  one  to  two  minutes,  from  ten 
to  fifteen  cells.  If  a  galvanic  batter}^  is  not  at  hand,  a  faradic 
current  can  be  employed. 

The  efforts  at  resuscitation  should  not  cease  for  less  than  half 
an  hour,  and  requires  the  efforts  of  several  assistants.  In  some 
instances,  in  India,  they  have  kept  it  up  with  ultimate  success 
after  three  hours. 

The  efforts  should  not  be  rough,  but  gentle,  rhythmal  and 
continuous,  using  all  the  rational  means  that  are  known  to  have 
given  success.  Never  employ  excessive  doses  of  alcohol,  brandy, 
digitalis,  atropia,  or  strychnia.  In  certain  diseased  conditions, 
severe  and  rough  treatment  at  resuscitation  cause  certain  death, 
as  in  aortic  and  mitral  regurgitation  with  fatty  heart,  hgemop- 
tysis,  and  tuberculosis. 

In  the  selection  of  an  anaesthetic  we  must  choose  the  one 
that  is  the  most  safe  under  the  particular  conditions  of  the 
individual  case.  A  few  important  words  which  are  to  be  fully 
comprehended  by  the  student : 

Asphyxia  is  the  suspension  of  vital  phenomena,  a  darkening 
of  the  lips  and  skin,  and  no  pulse.  When  complete  there  is 
paralysis  of  the  respiratory  centre.  Its  cause  may  be  (a)  the 
anaesthetic  alone,  (h)  the  anaesthetic,  plus  venous  blood,  (c) 
venous  blood  alone,  id)  irrespirable  gases. 

Blood-pressure  is  regulated  in  one  of  the  following  ways  :  1 . 
By  the  heart  directly  in  the  force  and  frequency  of  its  beat. 
2.  By  the  heart  directly,  by  sending  impulses  along  the  depres- 


498  AETinCIAL    ANAESTHESIA. 

sor  nerve  to  tlie  vaso-constrictor  centre,  inhibiting  its  cause  of 
this  fall  of  pressure. 

Cardiac  failure^  primar}^  cardiac  arrest,  lowering  of  blood- 
pressure  and  form  of  heart,  the  incomplete  mechanism  as  a 
force  in  the  circulation. 

Snycope,  to  faint,  a  temporary  or  permanent  suspension  of 
the  functions,  both  of  respiration  and  circulation,  from  a  sud- 
den lowering  of  blood-pressure,  sufficient  to  induce  stasis  of  the 
cerebral  circulation  and  unconsciousness. 

Shock  may  be  partial,  complete  or  reflex,  the  inhibition  of  a 
number  of  nerve  centres.  The  vaso-constrictor  centre  is  always 
more  or  less  involved.  Reflex  surgical  shock  is  a  result  of  the 
reception  of  painful  impression  on  the  central  nervous  system. 

Additional  Means  of  Resuscitation  During"  the  Ad- 
ministering- of  Anaesthetics. 

In  "Konig's"  method,  the  operator  stands  upon  the  pa- 
tient's left  side  and  faces  him,  and  laj^s  the  open  hand  upon  the 
patient's  chest,  with  the  ball  of  the  thumb  between  the  apex- 
beat  of  .the  heart  and  the  edge  of  the  sternum,  and  presses  the 
chest-wall  quickly  and  strongly  thirty  times  every  minute.  This 
plan  owes  its  efficacy  to  direct  action  upon  the  suddenly  failing 
heart. 

Dr.  Kelly,  of  Johns  Hopkins  Hospital,  Baltimore,  pursues 
the  following  plan  in  chloroform-asphj^xia : 

"The  anaesthetic  is  at  once  suspended,  the  wound  is  pro- 
tected, and,  if  abdominal,  a  broad  piece  of  gauze  is  laid  over 
the  intestines  under  the  incision.  An  assistant  steps  upon  the 
table  and  takes  one  of  the  patient's  knees  under  each  arm,  and 
thus  raises  the  body  from  the  table  until  it  rests  upon  the 
shoulders.  The  anaesthetizer  at  once  brings  the  patient's  head 
to  the  edge  of  the  table,  where  it  hangs  extended,  with  the 
trachea  and  nasal  cavity  in  line.  The  operator  stands  at  the 
head  and  institutes  respiratory  movements  as  follows :  mspii'a- 
tion,  by  placing  the  open  hands  at  each  side  of  the  chest  poste- 
riorly over  the  lower  true  ribs  and  drawing  the  chest  forward 
and  outward,  holding  it  thus  for  two  seconds  ;  expiration,  by 
reversing  the  movement,  by  placing  the  hands  on  the  front  of 


ADDITIONAL    MEANS    OF    RESUSCITATION.  499' 

•the  chest  over  the  lower  ribs  and  pushing  them  backwards  and 
inward,  at  the  same  time  compressing  the  chest.  The  success 
of  the  manoeuvre  will  be  demonstrated  b}'  the  rush  of  air  in  and 
out  of  the  chest.  The  heart  and  pulse  should  be  carefully 
watched.  As  the  respirator}'  movements  are  continued,  a  little 
flickering  pulse-wave  will  be  observed  at  the  wrist,  which  shortly 
becomes  faint  and  regular,  and  gradually  increases  in  strength. 
From  10  to  30  of  these  respiratory  movements  will  be  sufficient 
to  excite  voluntary  breathing.  Movements  must  be  timed  to 
suit  the  natural  efforts.  This  method  is  not  available  in  cases 
of  patients  with  constricted  fusiform  chests  (tight  lacers) ;  in 
such  cases  direct  antero-postenor  (?)  compression  must  be  prac- 
ticed over  the  lower  third  of  the  sternum  with  one  hand  there 
and  the  other  placed  on  the  back  at  a  point  opposite  the  one  in 
front." 

It  is  stated  that  Dr.  Kelly^  has  had  fifteen  cases,  up  to 
1894,  of  resuscitations  by  following  this  method.  It  is  to  be 
remembered  that  the  doctor  lives  in  the  southern  portion  of  our 
country,  Maryland,  and  we  have  already  stated  that  in  warm 
latitudes  like  our  southern  country,  Africa  and  India,  chloro- 
form can  be  administered  with  much  more  safety.  Again,  Dr. 
Kelly  has  a  large  corps  of  both  male  and  female  assistants  to 
carry  out  the  various  steps  of  artificial  respiration,  just  as  they 
have  in  India.  Dr.  Kelly's  assistant  is  a  most  competent 
medical  man,  on  whom  he  depends  to  give  the  anaesthetic  ;  he 
has  nothing  else  to  do  but  to  attend  to  this  one  object,  and  Dr. 
Kelly  is  a  most  rapid  and  brilliant  operator,  as  we  have  had  the 
opportunity  to  note  ;  he  is  ever  watchful  of  his  patient,  and 
ready  on  the  instant  the  heart  shows  any  indication  to  weaken, 
to  direct  that  anaesthetics  should  at  once  be  stopped,  and  resus- 
citative  measures  instituted.  Again,  he  is  most  careful  not 
only  of  the  pulse  but  also  the  respiration  in  every  case,  showing 
he  is  no  believer  in  the  Sims  and  Lawrie  doctrine  of  only  atten- 
tion to  the  respiration. 

*  Johns  Hopkins  Hospital  Eeports,  vol.  iii.,  Nos.  7,  8,  9,  1894,  and 
illustrations  kindly  sent  by  Dr.  Cullen. 


500  ARTIFICIAL    ANiESTHESIA. 


CHAPTER    XXIII. 

Experimeuts  of  Dr.  H.  C.  Wood  and  Dr.  Hobart  A.  Hare  in  Reply  to 
the  Hyderabad  Commissions,  February,  1890,  and  of  Dr.  Hare  and 
Dr.  Thornton  in  1893. 

After  a  careful  series  of  parallel  experiments,  especially  in 
reference  to  the  result  of  the  influence  of  chloroform  on  dogs, 
were  noted  the  following  conclusions  :'^  "As  we  use  between 
us,  in  the  laborator}^  of  the  University  of  Pennsjdvania,  many 
dogs  yearly,  a  very  large  proportion  of  which  are  finally  killed 
by  chloroform,  we  may  be  excused  for  our  positive  statement 
that  chloroform  is  a  cardiac  jparalyzant^  and  does  kill  dogs  by 
a  direct  action  upon  the  heart,  or  its  contained  ganglia,  espe- 
cially since  we  have  been  strengthened  in  our  opinion  by  the 
fact  that  Dr.  E.  T.  Reichert,  Professor  of  Physiology  at  the 
University  of  Pennsjdvania,  has  reached  results  confirming  our 
own,  and  has  frequently  demonstrated  the  same  to  the  Univer- 
sity classes.  .  .  , . .  It  has  been  the  custom  of  one  of  the  authors 
of  these  experiments  in  his  lectures  before  the  University  class 
to  demonstrate ,  by  means  of  the  respiratory  tembour,  the  mer- 
curial manometer  and  the  kymography,  a  continuation  of  respi- 
ratory movements  after  cardiac  arrest  through  chloroform. 
Further  than  this,  we  have  at  various  times  taken  tracings 
proving  the  same  facts. 

"The  statements  that  have  recently  been  made  in  the  Indian 
journals  and  in  the  London  Lancet  have  led  us  to  re-examine 
the  subject,  and  to  make  a  series  of  experiments  upon  it  with 
great  care.  We  have  also  varied  and  extended  these  experi- 
ments in  order  to  determine  whether  chloroform  paralyzes  the 
heart  by  indirect  action  through  the  vagus. 

"The  experiments  show  that  chloroform  acts  as  a  powerful 
depressant  poison  upon  respiration  and  circulation  ;  that  some- 
times the  influence  is  most  felt  at  the  heart,  and  death  results 

*  Medical  News,  February  22,  1890. 


EXPERIMENTS  OF  DR.  WOOD  AND  DR.  HARE.   501 

from  cardiac  arrest,  and  that  in  other  cases  the  drug  paralyzes 
primarily  the  respiratory  centres,  while  in  other  instances  it 
seems  to  act  with  equal  force  upon  the  medulla  and  heart. 

"So  far  as  practical  medicine  is  concerned  it  makes  little 
diflference  whether  the  heart  stops  just  before  or  just  after 
respiration,  so  that  these  cases  in  which  cardiac  arrest  and 
respiration  arrest  are  almost  simultaneous,  are,  for  the  purpose 
of  the  clinician,  the  same  as  these  in  which  heart  arrest  pre- 
cedes respiratory  paralysis. 

"  Finally,  the  results  also  coincide  with  our  previous  experi- 
ence in  the  laboratory,  and  with  what  we  believe  to  be  the  gen- 
eral belief  of  physiologists — that  cardiac  arrest  is  specially 
prone  to  occur  when  chloroform  is  administered  rapidly  and  in 
concentrated  form. ' ' 

These  two  sets  of  experiments  may  be  in  part  accounted  for, 
and  are  given  by  Dr.  Wood.* 

He  stated  "that  he  did  not  desire  to  express  any  doubt 
whatever  as  to  the  correctness  of  the  experimental  data  of  the 
Hyderabad  Chloroform  Commission,  but  simply  claimed  that 
both  his  and  their  set  of  experiments,  although  they  had 
yielded  different  results,  had  been  properly  performed.  He 
suggested  that  high  heat  or  other  climatic  conditions  surround- 
ing the  pariah  dog  of  India  might  make  its  heart  less  sensitive 
to  the  action  of  chloroform  than  the  heart  of  the  dog  bred  in 
our  northern  climates. 

"In  March,  1892,  Surgeon  Lawrie  found  that  the  original 
propositions  of  the  Hyderabad  Chloroform  Commission  were 
not  received  with  that  degree  of  confidence  which  he  expected, 
especially  the  final  conclusions,  in  which  the  Commission  states 
that  chloroform  may  he  given  in  any  case  requiring  an  operation 
with  perfect  ease  and  absolute  safety^  so  as  to  do  good  loithout 
the  risk  of  evil.  Dr.  Lawrie  wrote  to  Dr.  Hare,  asking  him  if 
another  chloroform  research  could  be  instituted  for  the  govern- 
ment of  His  Highness  the  Nizam  of  Hyderabad,  who  agreed 
to  pay  the  entire  expenses.     It  was  stated  that  the  express  ob- 

*  Dr.  H.  C.  Wood's  Address  on  Anaesthesia  read  before  International 
Medical  Congress,  Berlin,  August  6,  1890. 


502  ARTIFICIAL    ANESTHESIA. 

ject  of  the  research  was  the  reconcihation  of  at  least  some  of 
the  contradictory  conclusions  reached  by  various  experimenters 
during  the  past  few  years." 

Dr.  Hare*  assented,  and  associated  with  him  Dr.  E.  Q. 
Thornton,  his  demonstrator,  not  inviting  Dr.  Wood  to  take 
any  part  in  it.  The  title  of  their  paper  was  "A  Study  of  the 
Influence  of  Chloroform  upon  the  Respiration  and  Circula- 
tion, "f  We  have  only  space  to  quote  a  brief  summary  of 
this  very  elaborate  paper  : 

Suniiiiary. 

' '  From  the  immense  number  of  observations ,  in  regard  to 
the  action  of  chloroform,  in  the  laboratory  and  in  the  operating- 
room,  it  is  evident  that  sufficient  data  are  at  hand  to  give  us 
material  to  reach  positive  conclusions,  and  that  the  contradic- 
tory results  hitherto  obtained  must  have  been  reached  by  misin- 
terpretation and  error  in  experimental  method,  tinctured  per- 
haps by  opinions  formed  previous  to  the  completion  of  a  line  of 
study.  There  are  certain  facts  in  regard  to  chloroform  which 
few  will  deny,  the  chief  of  which  are  that  it  has  the  advantage 
of  rapid  action  without  disagreeable  preliminary  or  subsequent 
symptoms ;  its  bulk  is  small  and  its  odor  agreeable,  but,  more 
important  than  all,  it  is  much  more  dangerous  than  ether. 

"Though  the  Hyderabad  Commission,  in  their  preliminary 
conclusions  (page  30,  paragraph  43)  assert  that  ether  is  as  dan- 
gerous as  chloroform  if  given  sufficiently  to  produce  true  anaes- 
thesia, we  believe  that  the  safety  of  ether  is  so  universally 
recognized  that  this  conclusion  of  the  commission  can  only  be 
excused  by  the  remembrance  that  ether  has  probably  been  used 
as  little  by  those  who  wrote  this  paragraph  as  chloroform  is 
used  in  many  parts  of  America.  This  possibility  is  made  a 
probability  when  we  read  that  '  if  surgeons  choose  to  be  content 
with  a  condition  of  semi- anaesthesia,  it  can  no  doubt  be  pro- 
duced with  perfect  safety,  though  with  discomfort  to  the 
patient,  by  ether  held  rather  closely  over  the  mouth.     Such  a 

*  Now  Professor  of  Therapeutics,  Jefferson  Medical  College;  for- 
raerly  connected  with  the  University  of  Pennsylvania. 
t  Pamphlet  published  by  G.  S.  Davis,  Detroit,  Mich.,  1893. 


SUMMARY.  503 

condition  of  imperfect  ana3sthesia  would  never  be  accepted  by 
any  surgeon  accustomed  to  operate  under  chloroform. '  That 
this  statement  shows,  to  put  it  mildly,  that  the  writer  knows 
not  whereof  he  speaks,  is  proved  by  the  universal  employment 
of  ether  by  hundreds  of  the  best  surgeons  the  world  over  in 
preference  to  chloroform.  Further  than  this,  medical  literature 
contains  so  many  statistical  papers  showing  the  small  percentage 
of  deaths  from  ether  as  compared  with  chloroform  that  this 
point  need  not  be  debated. 

"The  truth  about  the  fatty  heart  appears  to  be  that  chloro- 
form per  se  in  no  way  endangers  such  a  heart,  but,  on  the  con- 
trary, by  lowering  the  blood-pressure,  lessens  the  work  that  the 
heart  has  to  perform,  which  is  a  positive  advantage.  But  the 
mere  inhalation  of  chloroform  is  only  a  part  of  the  process  of 
the  administration  in  practice.  A  patient  with  an  extremely 
fatty  heart  may  die  from  the  mere  exertion  of  getting  upon  the 
operating-table,  just  as  he  may  die  in  mounting  the  steps  in 
front  of  his  own  hall  door,  or  from  fright  at  the  mere  idea  of 
having  chloroform  or  of  undergoing  an  operation,  or  during  his 
involuntary  struggles.  Such  patients  must  inevitably  die  occa- 
sionally during  chloroform  administration,  and  would  do  so 
even  were  attar  of  roses  or  any  other  harmless  vapor  substituted 
for  chloroform. 

"  [We  agree  entirely  with  this  statement;  but  as  chloroform 
has  confessedly  some  cardiac  action  and  a  very  positive  vaso- 
motor and  respiratory  eifect,  the  fatal  result  might  be  more 
direct.  ] 

"  Having  given  the  evidence  we  have  accumulated,  let  us  see 
what  practical  deductions  may  be  drawn. 

"From  a  careful  stud}"  of  the  experiments  so  far  reported, 
from  studies  made  by  one  of  us  some  two  years  ago  with  H.  C. 
Wood,  and,  finally,  from  the  careful  series  of  experiments,  we 
believe  that  the  question  can  be  settled  by  the  acceptance  of 
both  views  in  a  modified  form,  or,  in  other  words,  that  there  is 
no  real  antagonism  in  the  beliefs  that  chloroform  kills  by  de- 
pression of  the  heart  or  depression  of  the  respiration. 

"We  very  positively  assert  that  chloroform  practically  always 
kills  by  failure  of  respiration  when  administered  by  inhalation, 


504  ARTIFICIAL    ANAESTHESIA. 

provided — and  this  provision  is  most  important — that  the  heart 
of  the  anaesthetized  is  healthy,  and  has  not  been  rendered  func- 
tionally incompetent  by  fright  or  violent  struggles,  or,  again,  by 
marked  asphyxia.  By  a  healthy  heart  we  mean  one  which  has 
not  undergone  true  fatty  degeneration,  or  has  not  so  severe  a 
valvular  lesion  as  to  make  the  slightest  variation  in  the  even 
tenor  of  the  circulation  fatal. 

"That  the  circulatory  depression  may  be  dangerous  is  not 
only  evident,  but  it  is  stated  to  be  so  by  the  second  Hyderabad 
Commission  itself  at  the  end  of  paragraph  8.  This  circulatory 
depression  may  be  so  profound  that  recovery  is  impossible  even 
with  the  most  thorough  artificial  respiration,  a  fact  stated  by 
the  second  Hyderabad  Commission  in  paragraph  25,  which  we 
quote  in  this  paper.  This  emphasizes  the  fact  that  we  cannot 
afford  to  totally  ignore  the  effect  of  chloroform  on  the  circula- 
tion, and  we  cannot  consider  the  patient  in  danger  of  circulatory 
failure  only  when  the  respiration  ceases,  but  as  soon  as  it 

BECOMES  ABNORMAL. 

"1.  Is  chloroform  a  safe  anaesthetic? 

"2.  Are  we  to  watch  the  pulse  or  respiration  during  the  use 
of  the  drug,  and  what  are  the  signs  in  the  respiratory  function 
indicative  of  danger  to  the  patient? 

"  3.  What  is  the  true  cause  of  death  from  chloroform? 

"4.  Is  death  from  chloroform  possible  when  it  is  properly 
administered  ? 

' '  5.  Under  what  circumstances  is  the  surgeon  to  use  chloro- 
form in  preference  to  the  less  dangerous  anaesthetic  ether  ? 

' '  6.  What  is  the  best  way  of  administering  chloroform  ? 

"To  the  first  question  the  answer  is,  Yes,  for  the  majority  of 
cases,  jDrovided  it  is  given  by  one  who  is  skilled  in  its  use  and 
not  only  knows  how  to  give  it,  but  to  detect  signs  of  danger. 
It  is  not  so  safe  as  ether  at  any  time,  other  things  being  equal, 
and  never  so  safe  in  the  hands  of  a  tyro. 

"To  the  second  question  the  answer  is,  Watch  the  respiration, 
because  as  soon  as  enough  chloroform  is  used  to  endanger  the 
circulation,  the  respiration  will  show  some  signs  of  abnormality 
either  in  depth,  shallowness  or  irregularity.  In  other  words, 
the  very  effect  of  the  drug  may  be  to  cause  such  deep  and  rapid 


SUMMARY.  505 

respirations  that  an  excessive  quantit\'  of  the  drug  is  taken  into 
the  kings,  and  continues  to  be  absorbed  even  after  the  inhaler 
is  "withdrawn. 

"The  answer  to  question  3  is,  That  death  is  always  due,  in 
the  healthy  animal,  to  respiratory  failure,  accompanied  by  cir- 
culatory depression,  which  latter  may  be  severe  enough  to  cause 
death,  even  if  artificial  respiration  is  used  skilfully.  Death  only 
occurs  in  the  healthy  animal  when  chloroform  is  given  in  exces- 
sive quantities. 

"  Question  4  is  impossible  to  answer  for  man  from  the  basis 
of  experimentation,  as  we  cannot  produce  identical  diseased 
states  in  animals  with  those  developed  under  various  conditions 
in  man.  The  physician,  having  a  case  of  heart  disease, 
should  always  advise  the  patient  of  the  danger  of  any  anaes- 
thetic, and  he  should  remember,  whether  it  is  wise  to  tell 
the  patient  or  not,  that  anaesthesia  always  means  a  step 
towards  death  even  in  the  healthiest  of  men.  In  the  event 
of  a  death  under  chloroform,  the  physician  is  not  to  blame  if 
he  has  taken  proper  preliminary  precautions  and  given  the 
chloroform  properly. 

"  In  answer  to  Question  5  we  have  several  points  to  offer : 

"1.  Hot  climates  (where  ether  is  inapplicable),  where  a  free 
circulation  of  air  increases  the  safety  of  the  patient. 

"2.  Chloroform  may  be  used  whenever  a  large  number  of 
persons  are  to  be  rapidly  anaesthetized,  so  that  the  surgeon 
may  pass  on  to  others  and  save  a  majority  of  lives,  even  if  the 
drug  endangers  a  few,  as  on  the  battle-field,  where  only  a  small 
bulk  of  anaesthetics  can  be  carried. 

"  3.  Its  employment  is  indicated  in  cases  of  Bright' s  disease 
requiring  the  surgeon's  attention,  owing  to  the  fact  that  anaes- 
thesia may  be  obtained  with  so  little  chloroform  that  the  kid- 
neys are  not  irritated,  whereas  ether,  because  of  the  large  quan- 
tity necessarily  used,  would  irritate  these  organs.  Quantity  for 
quantity,  ether  is,  of  course,  the  less  irritant  of  the  two. 

"4.  In  cases  of  aneurism,  or  great  atheroma  of  the  blood- 
vessels, where  the  shock  of  an  operation  without  anaesthesia 
would  be  a  greater  danger  than  the  use  of  an  anaesthetic,  chloro- 
form is  to  be  employed,  since  the  greater  struggles  caused  by 

33 


506  ARTIFICIAL    ANAESTHESIA. 

ether  and  the  stimulating  effect  which  it  has  on  the  oirculation 
and  blood-pressure  might  cause  vascular  rupture. 

"5.  In  children  or  adults  who  already  have  bronchitis,  or 
who  are  known  to  bear  ether  badly,  or,  in  other  words,  have  an 
idiosyncrasy  to  that  drug,  chloroform  may  be  employed. 

"6.  Persons  who  struggle  violently,  and  who  are  robust  and 
strong,  are  in  greater  danger  from  the  use  of  chloroform  than 
the  sickly  and  weak,  probably  because  the  struggles  strain  the 
heart  and  tend  to  dilate  its  walls. 

"The  safest  method  of  administration  is  by  Lawrie's  or 
Esmarch's  inhaler,  because  these  provide  free  circulation  of  air 
and  do  not  distract  the  attention  of  the  anaesthetizer  from  the 
respiratory  movement  by  complicated  apparatus.  Apparatus 
imuch  like  these,  in  allowing  a  free  amount  of  air,  are  the  Hy- 
K^erabad  chloroform  inhaler  or  open-ended  cone,  with  Krohne's 
.and  Seseman's  respiration  indicator  attachment. 

"The  Junker  inhaler,  even  with  its  modifications,  is  too  com- 
;plicated  and  cumbersome,  and  while  less  chloroform  is  wasted 
in  administering  the  drug,  it  must  all  be  thrown  out  of  the  bottle 

■afterwards.    If  used  at  all,  it  should  be  used  with  the  increased 

; air-supply  and  respiration  indicator  of  Krohne  and  Seseman. 
"1.  The  chloroform  should  be  given  on  absorbent  cotton, 

•stitched  in  an  open  cone  or  cap.     (A  depression  made  through 

ithe  opening  in  the  inside  flannel  bag  will  answer  as  well.) 

"2.  To  insure  regular  breathing,  the  patient,  lying  down, 
with  everything  loose   about   the  neck,   heart   and  abdomen, 

,  should  be  made  to  blow  into  the  cone,  held  at  a  little  distance 

,  from  the  face.  The  right  distance  throughout  the  inhalation  is 
the  nearest  which  does  not  cause  struggling,  or  choking,  or  hold- 

■  ing  of  the  breath.  Provided  no  choking  or  holding  of  the 
breath  occurs,  the  cap  should  gradually  be  brought  nearer  to, 

:  and  eventually  may  be  held  close  over,  the  mouth  and  nose  as 

;  insensibility  deepens. 

"3.  The  administrator's  sole  object  while  producing  anaes- 

^  thesia  is  to  keep  the  breathing  regular.  As  long  as  the  breath- 
ing-is regular,  and  the  patient  is  not  compelled  to  gasp  in  chlo- 
roform at  an  abnormal  rate,  there  is  absolutely  no  danger  what- 
ever in  pushing  the.an^sthetic  till  full  anaesthesia  is  produced. 


SUMMARY.  507 

"  4.  Irregularity  of  the  breathing  is  generall}-  caused  by  in- 
sufficient air,  which  makes  the  patient  struggle  or  choke  or 
hold  his  breath.  There  is  little  or  no  tendency  to  either  of 
these  untoward  events  if  sufficient  air  is  given  with  the  chloro- 
form. If  they  do  occur,  the  cap  must  be  removed  and  the 
patient  must  be  allowed  to  take  a  breath  of  fresh  air  before  the 
administration  is  proceeded  with. 

"  5.  Full  anaesthesia  is  estimated  by  insensitiveness  of  the 
cornea.  It  is  also  indicated  by  stertorous  breathing  or  by  com- 
plete relaxation  of  the  muscles.  Directly  the  cornea  becomes 
insensitive  or  the  breathing  becomes  stertorous,  the  inhalation 
should  be  stopped.  The  breathing  may  become  stertorous  while 
the  cornea  is  still  sensitive.  The  rule  to  stop  inhalation  should, 
notwithstanding,  be  rigidly  enforced,  and  it  will  be  found  that 
the  cornea  always  becomes  insensitive  within  a  few  seconds 
afterwards. 

"  It  is  only  necessary  to  add  that  the  patient  should  be  so 
dressed  for  an  operation  that  his  respiratory  movements  can  be 
easily  seen  by  the  chloroformist.  In  the  climate  of  India  this 
is  not  difficult  to  manage,  but  it  is  rather  more  so  in  the  climate 
of  Europe  ;  so  that  in  this  respect,  and  in  this  respect  alone, 
the  chloroformist  in  England  iS  placed  at  a  distinct  disadvantage 
compared  with  the  chloroformist  in  India. 

"Note. — Since  writing  this  report  two  important  papers 
upon  this  subject  have  appeared  in  the  London  Lancet — the 
one  by  Graskell  and  Shore,  in  which  they  carried  out  a  complete 
line  of  ingenious  cross-circulation  experiments,  and  from  which 
they  conclude  that  the  fall  in  blood-pressure  seen  under  chloro- 
form is  due  to  cardiac  rather  than  vaso-motor  depression  ;  and 
another  paper,  published  by  Lawrie,  in  the  London  Lancet  for 
February  11,  1893,  in  which  he  refutes  the  statements  made  by 
Gaskell  and  Shore,  and  details  experiments  which  he  believes 
combat  those  of  the  two  investigators  just  named." 

An  abstract  of  both  of  these  papers  will  be  found  on  pp. 
280-299. 

According  to  Dr.  Hobart  A.  Hare,*  Larwie's  inhaler  consists 
of  four  bamboo  sticks  supporting  unbleached  muslin,  which 

*  Park's  Treatise  on  Surgery,  vol.  i.,  p.  295. 


508  ARTIFICIAL    ANESTHESIA. 

provides  a  free  circulation  of  air,  and  do  not  distract  the  atten- 
tion of  the  anaesthetizer  from  the  respiratory  movement  by 
complicated  apparatus.  Apparatus  much  like  these,  in  allow- 
ing a  free  amount  of  air,  as  the  Hyderabad  chloroform  in- 
haler, or  open-ended  cone,  with  Krohne  and  Seseman's  respi- 
ration indicator  attachment,  the  inner  lining  is  of  white  felt,  the 
outer  cone  is  leather.  It  can  be  used  directly,  or  by  the  air- 
pump  attached  to  the  top.  Krohne  and  Seseman  have  also 
made  a  modification  ol"  Junker's  inhaler,  with  a  respirator 
indicator,  but  even  with  this  indicator  it  is  considered  too  com- 
plicated. 

To  Prevent  tlie  Action  of  Chloroform  on  the 

Heart.* 

(We  give  also  the  opinion  of  Dr.  Guerin,  which  is  quite 
adverse  to  the  theory  upheld  by  Dr.  Souchon,  pp.  178,  269.) 

M.  A.  Guerin,  of  Paris,  stated  that  death  from  arrest  of  the 
heart  might  be  prevented  in  chloroform  anaesthesia,  simply  by 
having  the  patient  inhale  the  chloroform  only  by  the  mouth. 
In  death  from  arrest  of  the  heart  the  cardiac  muscular  fibres 
cease  to  contract  under  the  influence  of  a  nasal-nerve  reflex, 
which  causes  inhibition  of  the  heart  through  the  medium  of 
the  pneumogastric.  If  a  rabbit  be  made  to  inhale  chloroform 
directly  through  the  trachea  after  tracheotomy,  the  heart  is  in 
no  waj'^  afi"ected  ;  if,  however,  the  animal  be  made  to  inhale  it 
through  the  nose,  the  heart  is  arrested.  Now,  as  the  trachea 
has  been  cut  transversely,  the  chloroform  inhaled  by  the  nose 
cannot  pass  the  bronchi.  It  is,  therefore,  plain  that  the  anaes- 
thetic acts  upon  the  heart  movements  only  through  the  nasal 
nerves,  and  the  cardiac  nerves  of  the  pneumogastric,  the  for- 
mer acting  reflexly  upon  the  latter.  In  administering  chloro- 
form, therefore,  its  action  upon  the  nasal  nerves  should  be  pre- 
vented by  pressing  the  nose  of  the  patients  between  the  fingers 
of  the  hand,  holding  the  compress  until  anaesthesia  be  pro- 
duced, when  the  nasal  fossae,  being  also  anaesthetized,  will  have 
no  reflex  action. 

*  France.     Huitieme  Congres  Franpais  de  Chirurgie.    Meeting  at 
Lyons,  October  9  to  13,  1894. 


ANAESTHETICS.  509 

Dr.  W.  I.  Fleming,  in  a  discussion  on  anaesthetics,  stated 
that  he  found  house  surgeons,  as  a  rule,  who  came  to  Glasgow 
hospitals,  had  no  knowledge  whatever  of  the  mode  of  using 
ether,  and  he  was  obliged  to  train  them  to  it.  He  also  stated 
the  proneness  of  dogs  to  succumb  to  chloroform,  and  he  had 
been  compelled  as  a  matter  of  economy  to  use  ether  for  that 
purpose.  In  regard  to  cats  the  case  was  exactly  the  reverse, 
and  to  kill  a  cat  with  chloroform  was  a  difficult  thing.  This 
important  matter  of  idiosyncrasy  did  not  appear  to  have  been 
commented  upon  by  the  Commission."^ 

"I  think  we  have  not  to  look  far  to  find  the  reason  of  the 
greater  safety  of  ether.  The  full  bounding  pulse  of  ether  anaes- 
thesia shows  how  much  the  circulatory  system  is  stimulated  by 
it,  and  the  rapid  and  deep  character  of  the  breathing  proves  the 
same  influence  on  the  respiratory  organs.  So  if  instead  of  using 
an  anaesthetic  which  has  a  tendency  to  depress  both  the  respi- 
ration and  the  circulation  (as  chloroform  has),  we  employ  one 
that  has  a  direct!}'  stimulating  effect,  we  are  much  more  likely 
to  tide  these  '  morituri '  over  their  operations."! 


CHAPTER   XXIV. 

AnsBsthetics. 

Tlieii'  Talue  in  Disease— Wliicli  to  Avoid  and  Those 

to  Employ. 

First,  as  a  rule  in  diseases  of  the  hrain,  either  acute  or  chronic, 
cocaine  is  to  be  avoided.  Ether  has  been  found  one  of  the  most 
valuable  in  brain  affections  not  organic,  when  given  with  great 
care,  premised  with  a  few  inhalations  of  nitrous  oxide  gas,  and 
followed  by  the  inhalation  of  oxygen  gas. 

^-  G.  A.  Stockwell,  M.D.,  Detroit,  !Micli.,  Therapeutic  Gazette, 
August  15,  1890. 

t  John  Freemau,  F.E.C.S.,  in  Bristol  Medico-Chirurgieal  Journal, 
July,  1896. 


510  ARTIFICIAL    ANESTHESIA. 

In  Diseases  of  the  Heart. — In  a  fatty  heart  there  is  a  degene- 
ration of  the  muscular  fibres,  or  an  increase  in  the  quantity  of 
subpericardial  fat,  or  fatty  infiltration.  The  former  is  the  most 
serious  condition,  and  is  due  to  a  deficiency  in  the  supply  of 
oxygenated  blood  to  the  heart.  It  gives  rise  to  asthma,  an- 
gina pectoris,  and  tends  to  syncope  and  sudden  death.  In  fatty 
hearts  cocaine  and  chloroform  are  to  be  avoided,  while  ether 
and  oxygen  gas  have  been  found  to  be  the  remedies.  In  cardiac 
dyspnoea  these  two  agents  can  be  employed  as  anaesthetics  in 
the  horizontal  posture,  avoiding  all  hurried  movements. 

In  aortic  stenosis  or  valvular  disease.,  ether  is  not  to  be  em- 
ployed, but  a  mixture  of  chloroform,  ether  and  alcohol.  Ether 
is  to  be  avoided  in  all  pulmonary  diseases  of  an  acute  character. 

In  neuralgia,  valuable  results  have  been  obtained  from  cocaine 
as  a  local  anaesthetic,  with  morphia  and  the  anode  of  the  elec- 
trical current,  or  camphor  with  equal  parts  of  chloroform  ;  also 
chloride  of  ethyl  has  been  found  useful  in  local  neuralgic  pains 
as  a  local  application. 

In  neuralgia  over  various  parts  of  the  body,  nitrous  oxide 
can  be  employed  with  advantage  in  the  middle  of  the  day. 

In  nervous  aphonia,  not  organic,  with  intermittent  loss  of 
voice,  the  inhalation  of  nitrous  oxide  gas  followed  by  vapor  of 
ether,  will  restore  the  voice  ;  also  hot  water  in  tin  inhaler,  with 
compound  tincture  of  benzoin  or  guaiacum,  a  teaspoonful  in  a 
pint  of  water,  which  must  be  kept  hot. 

Diseases  of  the  Lungs. — Pure  nitrous  oxide  gas  can  be  admin- 
istered with  air,  but  do  not  cover  the  face,  as  it  has  to  be  care- 
fully watched  to  see  that  no  asphyxia  be  the  result  (it  is  also 
useful  in  aphonial  bronchial  asthma). 

In  pulmonary  phthisis,  as  a  rule,  use  the  inhalation  of  the 
spray  or  vapor  of  menthol  or  eucalyptus  in  alboline,  with  a 
portion  of  bromide  of  ethj4,  only  sufficient  to  tide  over  pain  if 
the  operation  is  short. 

When  there  is  a  tumor  or  foreign  body  to  be  removed  from 
the  larynx,  chloroform  is  to  be  preferred  to  ether,  but  in  post- 
nasal operations  for  the  removal  of  adenoid  growths  ether  is  to 
be  employed. 

When  it  is  absolutely  necessary  to  give  ether  in  case  of  slight 


ANESTHETICS.  511 

pulmonary  disease,  on  account  of  a  prolonged  operation,  the 
patient's  skin,  feet  and  body  are  to  be  kept  warm,  and  after  the 
operation  must  be  watched  until  reaction  has  taken  place. 
Watch  also  that  the  pulse  and  respiration  are  normal.  It  is 
well  to  use  the  inhalation  of  oxygen  gas  if  the  skin  become 
dark. 

In  all  diseases  of  the  Iddneij,  especially  in  Bright'' s  disease^ 
or  diabetes,  ether  must  not  be  employed,  nor  should  chloroform. 
Nitrous  oxide  gas  with  oxj-gen  is  one  of  the  best  anaesthetics  in 
this  form  of  disease.  Epilepsy  and  chorea,  when  not  of  an 
organic  character,  have  been  benefited  by  the  inhalation  of 
nitrous  oxide  gas.  Spraying  of  the  spine  by  ether  vapor,  and 
the  internal  administration  of  fluid  extract  of  cimicifuga 
racemosa,  have  been  found  very  useful. 

Nitrous  oxide  gas  has  been  found  useful  in  certain  hysterical 
conditions  when  not  dependent  on  organic  disease  of  the  brain. 

Ether  has  been  found  a  valuable  remedy  in  hysteria,  by  inha- 
lation or  administered  internally  in  capsules,  or  associated  with 
emulsion  of  gum  arabic  with  valerian,  asafoetida,  musk  or 
camphor. 

In  insomnia,  nitrous  oxide  gas  has  been  found,  at  times,  use- 
ful, but  not  proper  if  there  is  vascular  excitement,  marked 
arterial  tension  or  associated  with  diseases  of  the  arteries  or 
hypertrophy  of  the  heart.  In  these  latter  cases  the  bromides 
are  found  to  be  the  most  useful.  At  times  a  small  dose  of  the 
atropia  sulphate,  j^q  of  a  grain,  with  |^  of  a  grain  of  morphia 
sulphate,  will  relieve  pain  of  head,  from  loss  of  sleep,  only  to 
be  given  at  long  intervals. 

Sciatica  can  be  treated  successfully  by  the  subcutaneous  in- 
jections of  ether  or  chloroform,  or  given  internally  in  doses  of 
from  ten  to  fifteen  drops,  repeated  morning  and  evening  for 
three  days,  or  until  the  patient  is  relieved.  No  local  injurj^ 
results  by  this  method,  as  the  injections  are  made  by  the  ordi- 
nary method,  superficially,  not  deep.  The  objections  to  deep 
freezing  the  skin  bj^  ether,  rhigolene  or  ethyl  chloride  are  that 
the  skin  becomes  destroyed  and  ulceration  and  great  pain  follow. 

In  cerebral  surgery,  neither  opium  nor  morphia  should  be 
employed  prior  to  the  operation. 


512  ARTIFICIAL    ANESTHESIA. 

Ether  can  be  employed  in  abdominal  sur^ejery  in  conjunction 
with  oxj'^^en  gas,  to  prevent  the  belching  or  vomiting.  A  small 
dose  of  hydrochlorate  of  cocaine  has  been  found  very  useful. 
The  more  rapid  the  etherization  is  produced  without  air,  the 
greater  the  danger  of  asphyxia. 

Average  time  to  produce  complete  unconsciousness  by  ether 
is  from  seven  to  eight  minutes. 

Appearance  of  the  face  when  fully  under  ether,  chloroform  or 
nitrous  oxide  should  be  natural ;  anj^  deep  cyanotic  appearance 
denotes  approaching  asphyxia. 

The  pulse  at  the  wrist  and  the  temporal  artery  should  be  care- 
fully noted  by  the  angesthetizer  or  assistant. 

What  to  do  first  in  case  of  danger  :  "  See  that  there  is  no 
obstruction  to  the  respirator}^  passage  by  the  throwing  back  of 
the  paralyzed  parts  upon  the  larynx.  Use  the  method  of  Hare 
and  Martin  (see  p.  272).  Place  the  index  finger  of  each  hand 
upon  the  corresponding  cornua  of  the  hj^oid  bone,  while  the 
middle  fingers  rest  upon  the  angle  of  the  jaw,  and  then  press 
forward  and  upward,  the  same  force  serving  to  extend  the  head 
upon  the  neck ;  if  this  fails  to  open  the  glottis,  then  by  means 
of  a  towel  grasp  the  tongue  and  make  rhythmic  traction.  If  the 
tongue  cannot  be  held  by  this  means,  use  a  tenaculum  or  for- 
ceps, thrust  far  back  into  the  base  of  the  tongue,  and  draw  it 
forward."  "  According  to  Dr.  Wood,  inversion  of  the  body  at 
an  angle  of  forty  degrees  does  not  resuscitate  in  the  manner 
which  Dr.  Holmes  believed  when  the  circulation  has  practi- 
cally ceased  in  anaesthesia ;  inverting  the  body  must  cause  the 
blood  which  has  collected  in  the  extremely  relaxed  vessels  of 
the  abdomen  to  flow  into  the  right  side  of  the  heart  and  dis- 
tend it,  and  this  distension,  this  increase  of  intra-cardiac  pres- 
sure, may  at  a  critical  moment  have  an  influence  upon  the 
failing  organ  sufficient  to  recall  it  into  functional  activity.  The 
drug  to  be  employed  in  cases  of  weak  heart  is  full  doses  of 
digitalis  given  hypodermically,  either  before  the  administration 
of  an  anaesthetic  or  when  cardiac  collapse  occurs." 

The  use  of  amyl  nitrite  will  in  some  cases  cause  an  increase 
of  the  pulse- wave  when  passed  by  a  hand  spray  into  the  nostrils. 
Strychnine  has  been  found,  both  by  experiment  and  experience, 


CHLOROFORM    EMPLOYED    WITH    SAFETY.  513 

a  most  valuable  drug  in  raising  the  arterial  pressure  and  the  rate 
and  depth  of  the  respiration.  It  should  be  given  in  full  doses 
for  a  robust  adult ;  as  large  a  dose  as  xV  grain  has  been  given 
with  good  results.  But,  as  we  have  stated  before,  the  most 
wonderful  results  have  been  obtained  b\'  the  use  of  artificial  res- 
piration, Sylvester's  or  other  methods.  Then  we  have  the  forced 
respiration  by  the  foot-bellows  of  Dr.  George  E.  Fell,  by  "which 
air  is  'forced'  into  a  receiving  chamber,  which  in  turn  is  connected 
with  an  apparatus  for  warming  the  air,  and  a  valve  which  can 
be  opened  and  shut  by  a  movement  of  the  finger.  This  valve 
in  turn  leads  to  the  tracheal  tube.  When  the  valve  is  opened 
the  air  rushes  through  the  chamber  into  the  lungs  and  expands 
them  ;  when  the  finger  is  lifted  the  valve  shuts,  the  lungs  con- 
tract, and  so  respiration  goes  on.  Dr.  Wood*  has  suggested  a 
much  cheaper,  simpler,  and  probably  equally  efficient,  appa- 
ratus, which  may  consist  simply  of  a  pair  of  bellows  of  proper 
size,  a  few  feet  of  india-rubber  tubing,  a  face  mask  and  two 
sizes  of  inhalation-tubes.  There  should  also  be  set  in  the  rub- 
ber tubing  a  metal  tube,  similar  to  the  tracheal  canula  of  the 
physiological  laboratory,  so  that  it  is  in  the  power  of  the  operator 
to  allow  for  the  escape  of  any  excess  of  air  thrown  by  the 
bellows. ' ' 

In  Wliat  Class  of  Cases  can  Cliloroform  be 
Employed  with  Safetj? 

Chloroform,  in  certain  conditions,  is  a  direct  cardiac  depres- 
sant, while,  as  expressed  by  the  late  Dr.  Fordyce  Barker,  in 
obstetrics  he  had  found  that  "  chloroform  had  a  very  different 
effect  from  that  which  it  had  when  given  as  an  anaesthetic  in 
•surgical  practice.  The  reason  that  he  assigned  for  this  was, 
that  in  surgical  practice  the  anaesthetic  was  given  to  anticipate 
suffering,  while  in  the  case  of  the  parturient  woman,  it  was 
used  for  the  relief  of  pain  already  existing.  Under  the  latter 
circumstances  he  believed  the  system  would  tolerate  the  de- 
pressing influence  of  the  drug,  which  it  might  not  in  ordinary 
conditions." 

In  our  own  experience,  and  after  numerous  experiments,  we 

*  "Anaesthesia,"  by  H.  C.  Wood,  Pamphlet,  p.  33. 


514  ARTIFICIAL    ANiESTHESIA. 

would  limit  the  use  of  this  most  potent  of  all  the  anaesthetics 
to  very  young  children,  or  to  those  who  are  weak,  strumous,  or 
overgrown  ;  to  puerperal  eclampsia,  in  very  violent  convulsions 
in  male  adults,  or  in  females  during  delivery  where  rapidity  of 
dilatation  of  the  os  uteri  is  absolutely  necessary  to  save  the 
mother's  life. 

In  some  rare  cases  of  painful  operation,  where,  after  contin- 
ued efforts,  no  complete  insensibility  can  be  produced  by  ether, 
we  would  feel  justified  in  the  use  of  chloroform  on  a  clean 
sponge  or  inhaler. 

"There  are  certain  bodily  conditions,  hardly  to  be  spoken  of 
as  disease,  which  would  exert  some  influence  in  the  selection  of 
the  anaesthetic.  In  his  recent  book  Dr.  Frederic  W.  Hewitt 
states  that  old  persons  whose  chests  have  become  rigid,  seem 
not  to  be  able  to  respond  sufficiently  to  the  demand  made  upon 
them  by  ether,  and  that  very  old  persons  bear  chloroform  prac- 
tically well.  In  applying  such  a  principle  as  this,  it  must  be 
remembered  that  it  is  not  the  years  of  the  person,  but  the  ex- 
tent of  senile  changes  in  his  tissues,  which  should  influence  the 
ansesthetizer.  Dr.  Hewitt  recommends  in  such  cases  the  A.  C, 
E.  mixture  ;  if  such  mixture  be  employed,  it  should  always  be 
freshly  made  at  the  time  of  its  administration. 

"Extreme  obesity  is  another  bodily  condition  in  which  it  is 
affirmed  that  ether  is  often  not  well  borne,  producing  so  much 
excitement  and  respiratory  irritation,  as  to  forbid  its  use.  Under 
these  circumstances  again,  Hewitt  recommends  the  A.  C.  E. 
mixture,  but  states  that  there  are  certain  cases  in  which  chloro- 
form is  necessary  in  order  to  secure  sufficient  tranquillity  of 
breathing.  I  have  not  had  practical  experience  with  such  pa- 
tients of  sufficient  amount  to  be  weighty,  but  my  feeling  is  that 
in  such  cases  ether  should  be  first  tried,  and  then,  if  it  be  not 
well  borne,  chloroform  substituted,  ether  being  again  employed 
when  quiet  anaesthesia  has  been  thoroughly  established." 

In  this  connection  we  feel  as  if  it  would  be  well  to  give  the 
admirable  views  of  an  expert.  Dr.  John  N.  Upshur,  Richmond, 
Va. ,'^   on    "The  Therapeutic   Application    of  Chloroform    in 

*  Professor  of  Materia  Medica  and  Therapeutics,  Medical  College  of 
Virginia.    Trans.  Pan-American  Medical  Congress,  vol.  i.,  p.  922. 


CHLOROFORM    EMPLOYED    WITH    SAFETY.  515 

Labor."  In  the  south  of  our  country  it  is  stated  chloroform 
can  be  emplo.yed  with  perfect  safety,  although  we  have  our 
doubts,  and  have  expressed  them  freely  in  this  edition. 

"Since  the  primeval  curse  fell  upon  our  race,  and  pain  and 
anguish  have  been  the  invariable  and  dreaded  accompaniment 
of  man's  entry  into  the  world,  to  soothe  woman's  sorrows  and 
conduct  her  safely  through  the  crisis  is  an  object  worthy  our 
highest  effort,  and  one  to  be  sought  for  with  commendable  de- 
votion. 

"  To  accomplish  this  end  the  administration  of  chloroform 
has  become  a  routine  practice,  and  the  consensus  of  opinion 
from  a  very  large  number  of  obstetricians  is  in  favor  of  its 
safety  when  thus  exhibited.  Careful  observations  for  many 
years  has  tended  to  make  me  question  its  utility  in  many  cases  ; 
nay,  to  convince  me  that  oftentimes  it  adds  to  the  peril  and 
prolongs  the  trial. 

"In  the  light  of  the  foregoing  facts  I  most  earnestly  avow 
my  belief  that  we,  as  physicians,  should  place  chloroform  upon 
the  same  platform  as  other  drugs,  and  not  be  influenced  by  our 
sympathies  aroused  by  the  pleadings  of  patients  or  the  fash- 
ionable routine  practice  of  the  day,  but  initiate  and  sustain  a 
much  needed  reform  in  our  obstetric  work,  chloroform  being 
administered,  as  other  agents,  when  the  indications  in  the  case 
imperatively  demand  it — not  unless.  He  is  a  bold  man  who, 
invading  the  domain  of  nature,  interferes  with  her  physiologic 
processes  and  places  the  wife  and  mother  in  a  position  of  in- 
creased peril,  and  perchance  in  the  shadow  of  a  fatal  issue,  or 
at  least  of  a  life  of  invalidism  and  suffering,  where  before  the 
home  was  irradiated  with  the  effulgent  rays  of  the  sunlight  of 
true  and  unalloyed  happiness. ' ' 


516  ARTIFICIAL    ANESTHESIA. 


CHAPTER    XXV. 

The  Legal  Eesponsibility  of  Physicians  in  the  Administration  of  An- 
esthetics— Medico-legal  Relations  of  Ansesthetics — Experiments 
of  M.  Dolbeau — Case  in  Philadelphia  of  a  Surgeon  Dentist — The 
Important  Question  whether  Chloroform  can  be  Administered 
for  Criminal  Purposes? — Cases  in  France,  England  and  the  United 
States — Dr.  N.  L.  Folsom,  R.  M.  Denig — Chloroform  as  a  Poison — 
The  Chloroform  Habit — Hypnotic  Ansesthesia  and  its  Analogous 
States  in  their  Various  Aspects. 

On  tlie  Leg-al  Responsibility  of  Physicians  in  the 
Administration  of  Anaesthetics. 

It  is  a  noted  fact,  that  when  anaesthetics  are  trusted  in  the 
hands  of  an  educated  and  careful  surgeon,  the  mortality  from 
their  use  is  reduced  to  the  minimum.  The  individual  who  ad- 
ministers the  anaesthetic  should  have  nothing  else  to  do ;  his 
hands,  eyes  and  mind  should  be  on  this  alone.  In  our  hospitals, 
■clinical  assistants  should  be  instructed  for  at  least  six  months  in 
the  chemical,  physiological  and  toxicological  nature  of  anaes- 
thetic agents,  and  after  being  thoroughly  trained  in  their  use, 
and  in  the  means  of  resuscitation,  receive  a  certificate  of  com- 
petency. This  is  done  in  the  Philadelphia  Dental  College  after 
a  careful  examination  by  the  professors  and  an  expert.  It  is 
too  often  the  case  that  valuable  lives  are  placed,  as  it  were,  in 
the  hands  of  young  men  who  have  no  proper  knowledge  of  their 
use,  and  who  do  not  appreciate  the  great  responsibility  under 
which  they  are  laboring.  Such  powerful  agents  as  chloroform 
and  ether,  or  their  compounds,  should  be  handled  with  skill, 
judgment  and  discretion,  fully  realizing  that  on  the  exercise  of 
these  depends  the  life  of  the  patient.  There  is  no  doubt  that 
many  deaths  have  been  caused  through  the  want  of  this  proper 
knowledge  and  experience.  Who  is  at  fault  in  this  ?  It  is,  as 
a  rule,  the  fault  of  the  medical  schools  and  of  the  operating 
surgeon,  who,  in  a  general  way,  considers  this  as  a  secondary 
matter,  and  trusts  the  anaesthetic  to  any  person  who  may  be 


LEGAL    RESPONSIBILITY    OF    PHYSICIANS.  517 

with  him.  To  the  experienced  ej^e  signs  of  danger  are  almost 
always  evident — the  disturbed,  stertorous,  or  shallow  respira- 
tion, the  pulse,  the  pallid  or  leaden  hue  of  the  skin,  the  flutter- 
ing heart ;  but  on  the  novice  or  recent  graduate  these  make 
little  or  no  impression. 

We  repeat  it,  that  a  physician  or  a  surgeon,  in  administering 
ether  and  chloroform,  or  their  compounds,  is  responsible  for 
the  life  of  the  patient,  and  it  would  be  well  for  some  of  them  if 
laws  were  enacted  compelling  them  to  employ  the  least  fatal 
anaesthetic,  unless  some  idiosyncrasy  on  the  part  of  the  patient 
did  not  allow  of  the  use  of  such  an  agent,  or  one  less  dangerous. 
Again,  in  our  navy,  especially  on  board  steamers,  and  in  coun- 
tries where  the  average  temperature  is  80°  F.  or  over,  chloro- 
form might  be  allowed,  but  in  the  army,  in  the  field,  as  well  as 
in  the  navy,  only  in  capital,  very  painful  or  extensive  opera- 
tions, this  exception  being  enforced  by  a  rule. 

Daniel  S.  Riddle,  Esq.,  New  York,  said,  as  regards  the  enact- 
ment of  further  laws  on  this  subject,  it  was  not  necessary. 
There  are  sufficient  laws  already.  The  difficulty  is  in  enforcing 
them.  If  there  is  carelessness  on  the  part  of  the  doctor,  he 
should  be  held  responsible.  It  is  the  same  with  lawyers.  It 
belongs  to  the  profession  of  medicine  to  say  whether  these 
agents  have  been  carelessly  used;  and  if  they  have  been  care- 
lessly used,  it  is  their  duty  to  produce,  as  well  as  indicate,  the 
person  who  uses  these  great  powers  carelessly.  "If  we  law- 
yers," he  remarked  facetiously,  "find  out  that  you  are  carelessly 
using  these  things,  it  is  our  duty  to  pitch  in." 

Coroner  Ellinger  thought  it  would  be  a  hard  matter  to 
hold  doctors  responsible,  because  it  is  difficult  to  state  scientifi- 
cally where  the  responsibility  can  rest.  It  ought  at  least  to  be 
shown  that  there  was  conscious  negligence  in  the  performance 
of  duty.  The  condition  of  the  patient  should  be  taken  into 
account,  and  that  must  be  left  to  the  discretion  and  knowledge 
of  the  attending  surgeon.  He  thought  that  the  medical  stu- 
dent ought  to  be  taught  the  danger  of  the  agent  he  employs, 
how  and  when  to  use  it  judiciously,  and  should  be  required  to 
secure  a  certificate  to  the  efi'ect  that  he  has  been  so  instructed 
before  being  let  loose  upon  the  public.     The  public  would  then 


518  ARTIFICIAL    ANiESTHESIA. 

know  that  he  possesses  a  knowledge  of  the  agent  which  he  em- 
ploys. Beside,  the  phj^sician  would  be  conscious  of  a  certain 
moral  responsibility,  for  he  held  that  the  moral  responsibility 
which  every  medical  gentleman  must  feel,  is  greater  than  the 
responsibilities  placed  upon  him  by  the  laws  of  the  land. 

Jacob  F.  Miller,  Esq. ,  agreed  with  those  who  advocated  care 
in  the  use  of  these  agents.  Man  is  living  in  the  midst  of  dan- 
gerous forces,  and  will  continue  to  use  them,  though  of  neces- 
sity many  deaths  occur.  But  in  order  to  rest  a  case  against 
the  user,  it  is  necessary  to  show  negligence.  Negligence  is  the 
gist  of  the  action.  The  physician,  surgeon  or  lawyer  contracts 
for  the  ordinary  skill  and  care  of  his  profession.  He  does  not 
contract  for  any  extraordinary  skill.  The  law  does  not  hold 
him  any  more  responsible  than  that.  It  would  be  unreason- 
able to  do  so,  because  few  persons  could  safely  practice  their 
profession ;  and  if  any  person  should  use  anaesthetics,  and  the 
patient  should  die,  that  is  not  sufficient  to  charge  him  with 
the  responsibility.  He  thought  that  all  would  admit  that  if  a 
man  not  having  the  ordinary  skill  of  his  profession  should,  by 
unskilful  administration  of  anaesthetics,  cause  the  death  of  the 
patient,  he  should  be  prevented  from  doing  further  damage  by 
a  suit  for  malpractice.  Would  it  not  be  better  to  stop  him  by 
such  procedure  ?  Shall  a  man  be  allowed  to  use  such  danger- 
ous forces  just  as  he  pleases — let  the  consequences  be  what 
they  may?  People  consult  phj^sicians  because  they  say  they 
have  the  requisite  skill  to  use  these  things.  They  hold  them- 
selves out  to  the  community  as  having  this  skill,  and  they 
ought  to  possess  it ;  if  they  do  not,  and  harm  results  from  it, 
they  ought  to  be  held  responsible.  The  coroner  says  that" 
physicians  are  actuated  by  moral  responsibility,  which  is  no 
responsibility  at  all.  The  quack  will  go  on  with  his  practices 
until  he  is  stopped  by  the  law.  Where  is  his  moral  responsi- 
bility ?  What  does  he  care  ?  His  practice  only  goes  to  show 
that  he  has  no  moral  responsibility.  That  lawyers  should  check 
such  practices  is  due  to  the  profession^  to  the  public,  and  to  God. 
But  before  they  take  a  case  of  malpractice  they  ought  to  be  con- 
vinced that  there  is  malpractice.  It  may  be  all  very  well  to  say 
that  negligence  is  the  gist  of  an  action.     If  it  cannot  be  shown 


LEGAL    RESPONSIBILITY    OF    PHYSICIANS.  519 

that  there  is  negligence,  the  case  should  not  be  takeji,  for  when 
the  case  arrives  at  the  courts  you  must  show  that  the  defendant 
is  guilty  of  neglect,  and  that  is  done  by  calling  upon  a  i)hysician 
who  is  able  to  say  where  negligence  has  been  committed,  and 
that  he  is  guilty  of  it.  This  evidence  is  necessary ;  lawyers 
cannot  get  along  without  it. 

Mr.  Max  F.  Eller  spoke  of  the  fact  that,  for  any  action,  as 
many  "experts"  could  be  obtained  by  one  as  the  other,  pro- 
vided enough  money  is  paid  for  such  expert  testimony.  Some 
will  say  the  patient  should  have  been  notified  of  the  danger  ; 
others  that  he  ought  not.  Some  will  say  the  chloroform  killed 
him  ;  others  not.  For  that  reason  he  thought  that  before 
making  any  more  laws  regarding  the  proper  administration  of 
anaesthetics,  those  which  already  exist  should  be  administered 
in  a  better  manner,  and  physicians  should  be  a  little  more  care- 
ful how  they  administer  anaesthetics. 

Mr.  Eller  referred  to  the  popular  fallacy  that  chloroform 
could  be  used  successfully  for  the  purpose  of  effecting  robbery. 
He  thought  that  that  delusion  ought  to  be  dispelled,  for  the 
time  between  the  actual  administrstion  of  chloroform  and  the 
period  of  annihilation  of  sensation,  is  sufficiently  long  to  render 
the  accomplishment  of  the  object  impossible.  Such  a  plea  is 
used  by  criminals  to  shield  themselves  from  the  consequences 
of  their  own  crimes.  In  this  we  differ  from  Mr.  Eller,  and 
have  collected  some  important  evidence  in  its  favor. 

A  correspondent  of  the  Societe  d^ Hygiene  et  de  Medicine 
Legal,  Paris,  having  been  interrogated  as  a  judicial  expert  as 
to  "whether  the  emploj^ment  of  narcotics,  in  the  liquid  or  gas- 
eous state,  can  produce  an  anaesthesia  so  profound  that  viola- 
tion of  the  persons  to  whom  it  has  been  given  may  be  perpe- 
trated without  awakening  them,"  gave  an  affirmative  answer. 

M.  Dolbeau,  apropos  to  his  judgment,  made  a  series  of  re- 
searches, the  results  of  which  were  laid  before  the  society.  He 
limits  the  question  to  the  employment  of  chloroform,  and  starts 
with  the  following  proposition  : 

' '  Can  chloroform  in  vapor  he  administered  to  a  person  who  is 
sleeping  naturally,  to  the  production  of  ancesfhesia ,  without  awak- 
ening him?^^ 


520  ARTIFICIAL    ANAESTHESIA. 

In  M.  Dolbeaivs  experiments  the  chloroform  was  given  id 
the  usual  manner,  on  a  cone  held  an  inch  or  so  above  tlie  nos- 
trils, so  as  to  enable  a  constant  view  of  the  countenance. 

In  the  first  series  of  experiments  three  patients  out  of  four 
were  awakened  bj'  the  chloroform  inhalations ;  in  the  second 
series,  four  out  of  six  ;  in  the  third,  only  three  out  of  nine. 

It  is  not  without  interest  to  observe  the  increasing  proportion 
of  subjects  anaesthetized ;  the  manual  dexterity'  acquired  by 
the  experiments  is  not  without  influence  upon  the  results  ob- 
tained. Accordingly,  as  a  result  of  his  experiments,  M.  Dol- 
beau  believes  himself  authorized  to  formulate  the  following 
conclusions  : 

"  Scientifically,  it  is  difficult,  but  often  possible,  to  cause  in- 
sensibility by  means  of  chloroform  in  persons  who  are  sleeping 
a  natural  sleep.  Certain  precautions — the  employment  of  a 
perfectly  pure  agent  and  experience — are  also  conditions  which 
favor  the  attempt  at  anaesthesia. 

"It  is  probable  that  certain  subjects  are  absolutely  refractory 
— that  is  to  say  that  it  is  impossible  to  anaesthetize  them  with- 
out taking  every  precaution.  Others,  on  the  contrary,  particu- 
larly young  children,  submit  easily  to  anaesthesia  without  having 
been  awakened  by  the  irritation  produced  by  the  anaesthetic 
agent  in  the  air-passages. 

"From  a  criminal  point  of  view  it  is  certain  that  chloroform, 
administered  to  sleeping  individuals,  may  facilitate  the  perpe- 
tration of  certain  crimes.  It  is,  however,  probable  that  the 
conditions  favorable  to  anaesthesia  are  rarely  found  on  the  oc- 
casion of  criminal  attempts.  In  justice,  the  expert  should 
declare  that  it  is  possible,  but  not  easy,  to  render  a  person  who 
sleeps,  so  insensible  by  chloroform  that  the  said  person  might 
become  the  victim  of  any  violence. 

"  The  responsibility  attending  the  use  of  anaesthetics  is  of 
great  importance  to  medical  men,  as  frequently  their  personal 
and  professional  reputation  is  at  stake ;  it  is  therefore  always 
better,  in  the  administration  of  an  anaesthetic  to  a  female^  to 
have  some  reliable  person  present.  This  is  especially  necessary 
when  ether  or  chloroform  is  employed." 

During  the  early  period  of  the  author's  medical  career,  soon 


LEGAL    RESPOXSIBILITY    OF    PHYSICIANS.  521 

after  graduating,  we  had  in  our  Quiz  class  a  young,  ambitious 
dental  surgeon,  one  of  the  most  gentle  and  amiable  of  men, 
who  was  desirous  of  obtaining  the  medical  degree,  which  he 
ultimately  attained.     Soon   after  this  the  man  was  married, 
settled  in   this  city,  and  acquired  a  large  business.     At  that 
time  it  was  common  for  the  dentist  to  administer  angesthetics 
in  their  office  without  an  attendant  in  the  extracting  of  teeth, 
etc.      He   had   a  young  female   patient  to  whom  he  admin- 
istered chloroform  alone,  and  who  afterwards  stated  that  he 
had  taken  improper  liberties  with  her  person  during  this  state. 
This  case  caused  great  excitement  in  our  city,  and  the  public 
sympathy  was  with  the  young  female,  and  a  suit  was  insti- 
tuted in  which  damages  were  claimed.    The  case  was  argued 
by  distinguished  lawyers  on  both  sides,  and  voluminous  testi- 
mony taken.     The  judge  charged  the  jury,  and  the  sentence 
was  ten  years'  imprisonment.     Subsequently  the  sentiment  of 
the  community  changed,  and  it  believed  it  was  all  the  result 
of  her  vivid  imagination,  and  that  she  was  laboring  under  a 
delusion.     The  majority  of  physicians  and  dentists  signed  a 
petition,  and  the  sentence  was  remitted. 

"It  is  stated  by  Taylor  'that  the  vapors  of  ether  and  chlo- 
roform have  been  criminally  used  in  attempt  at  rape.     In  a 
case  which  occurred  in  France,  a  dentist  was  convicted  of  this 
crime  upon  a  woman  to  whom  he  had  administered  the  vapor 
of  ether.'     Xow  this  may  be  just  such  a  case  as  the  one  in 
our  own  city.      Ether,   from   its  disagreeable  taste  and  irri- 
tating vapor,  is  much  more  difficult  to  administer  forcibly  and 
against  the  will  of  a  patient.     The  numerous  stories  of  anes- 
thesia b}^  simply  placing  a  few  drops  on  a  handkerchief  under 
a  patient" s  nose  or  mouth  are  in  the  majority  of  cases  perfectly 
absurd,  as  the  shortest  time  required  to  bring  a  patient  fully 
under  the  influence  of  either  of  these  drugs— even  when  forci- 
bly held  in  contact— is  from  two  to  ten  minutes,  and  if  subse- 
quent rough  handling  takes  place  the  patient  is  at  once  roused 
to  make  resistance  by  struggling.     ^Ve  were  once  called  to  a 
woman^  who  had  been  in  the  habit  of  employing  chloroform  by 
inhalation  from  a  small  bottle  to  cause  sleep  ;  she  accidentally, 
when  in  a  drowsy  state,  let  the  open  bottle  drop  on  the  pillow' 

34 


522  ARTIFICIAL    ANAESTHESIA. 

and  its  contents  saturating  the  covering,  she  laj''  with  her 
face  in  it.  But  instead  of  making  her  sleep  soundl}^,  it  pro- 
duced most  distressing  nausea,  and  her  family  were  awakened 
by  her  efforts  at  vomiting,  and  so  her  life  was  saved,  she  not 
being  able  to  arouse  suflSciently  to  get  rid  of  the  offending  mat- 
ter, which  would  have  lodged  in  her  trachea,  or  the  contents  of 
the  stomach  might  have  been  brought  into  the  bronchial  tubes 
by  deep  inspiration,  and  thus  have  caused  suffocation.  But  it 
is  not  always  the  result,  as  persons  have  emploj^ed  this  means 
to  produce  death  and  have  been  successful." 

The  former  case  in  Philadelphia  settled  the  important  point 
in  the  minds  of  medical  men  of  this  city  that  this  incomplete 
unconsciousness  does  not  coexist  with  complete  motor  and  sen- 
sory anaesthesia,  and,  therefore,  anaesthetics  are  employed  with- 
out any  fear  in  all  important  operations.  These  observations 
are,  in  part,  corroborated  by  two  learned  authors  in  a  recent 
and  most  admirable  work  on  medical  jurisprudence,  in  which 
they  state : 

"A  question  of  some  importance  to  the  medical  jurist  natu- 
rally occurs  here,  namely  :  '  Wliether  cldoroform  can  he  adminis- 
tered for  improper  jyurposes  f^  We  know,  however,  that  insen- 
sibility from  chloroform  (and  more  slowly  from  ether)  vapor  is 
only  slowly  induced.  It  would  be  difficult,  therefore,  to  admin- 
ister chloroform  forcibly  and  against  the  will,  while,  of  course, 
the  stories  of  immediate  anaesthesia  produced  bj^  it  are  but  idle 
fables.  Still,  it  might  be  administered  to  persons  asleep  with- 
out much  difficulty,  and  this  seems  the  only  possible  condition 
under  which  it  could  be  convenientlj^  used  for  improper  pur- 
poses unless  considerable  force  were  employed  to  prevent  the 
person  struggling,  which,  under  ordinary  circumstances,  would 
be  an  almost  insurmountable  difficulty  to  its  use." 

The  following  case,*  which  occurred  in  England,  more  com- 
pletely confirms  our  case  of  the  condition  of  semi-angesthesia  : 

"A  case  of  the  utmost  importance  to  the  whole  profession, 
not  in  G-reat  Britain  only,  but  everywhere,  was  tried  before  Mr. 
Justice  Hawkins,  at  the  assizes,  at  Northampton,  on  the  9th 

■-'•  Philadelphia  Medical  Times,  December  22,  1877. 


LEGAL    RESPONSIBILITY    OF    PHYSICIANS.  523 

of  November.  It  was  a  charge  against  a  surgeon's  assistant  of 
criminal  assault — of  rape  upon  a  patient  when  under  the 
influence  of  chloroform.  If  there  is  a  dastardly  crime,  it  is  to 
take  advantage  of  a  woman's  helpless  unconsciousness  to  vio- 
late her  person.  And  so  the  magistrate  thought  who  sent  the 
accused  to  jail,  on  the  14th  of  September,  declining  to  hear 
anything  in  his  favor,  and  resolutely  refusing  to  accept  bail. 
The  charge  was  that  a  married  woman,  named  Child,  went  to 
the  surgery  of  her  family  medical  attendant  to  have  her  teeth 
operated  upon.  She  had  been  there  a  day  or  two  before,  but 
the  attempt  to  put  her  under  chloroform  then  failed.  A  second 
attempt  was  rather  more  successful.  She  evidently  had  some 
peculiarities  or  idiosyncrasies  in  relation  to  chloroform,  for  he 
gave  it  for  an  hour,  and  yet  she  was  never  sufficiently  under  its 
influence  to  admit  of  the  operation  being  performed.  She  was 
accompanied  by  a '  friend — a  Miss  Fellows.  At  the  end  of 
the  hour,  Miss  Fellows  went  out  of  the  room.  In  a  quarter 
of  an  hour  Miss  Fellows  returned.  The  prosecutor  main- 
tained that,  on  Miss  Fellows' s  return,  she  was  quite  con- 
scious, but  unable  to  speak.  Finding  it  impossible  to  perform 
the  operation,  the  accused  accompanied  the  prosecutrix  and 
her  friend  home.  So  far,  Mrs.  Child  had  been  unable  to  speak, 
but  shortlj''  after  the  accused  left  the  house  she  complained  to 
her  husband  that  he  had  taken  advantage  of  the  absence  of 
Miss  Fellows  to  assault  her  criminally'.  Next  day,  when  the 
accused  called,  he  was  told  about  what  she  had  said,  and  he  re- 
plied that  she  was  laboring  under  a  delusion.  Under  cross- 
examination,  Mrs.  Child  said  that  she  told  the  accused  that  if 
he  would  admit  the  off"ence  and  quit  the  town  (Birmingham)  she 
would  forgive  him.  This  the  accused  declined  to  do,  denying 
that  he  had  committed  any  ofi"ence.  He  was  then  given  in  cus- 
tody. The  prosecutrix  stated  that  the  ofl"ence  was  perj)etrated 
immediately  after  Miss  Fellows  left  the  room  ;  that  the  prisoner 
went  upon  his  knees,  and  then  assaulted  her.  Miss  Fellows 
stated  that  on  her  return  she  found  3Irs.  Child  in  precisely  the 
same  position  in  the  chair  which  she  occupied  when  she  went 
out  of  the  room.  Such  were  the  facts  of  the  case.  It  was  quite 
clear  that  there  had  been  either  an  assault  committed,  or  that 


524  ARTIFICIAL    ANESTHESIA. 

the  woman  was  under  the  influence  of  a  very  pronounced  delu- 
sion. The  whole  of  the  accused's  conduct  was  in  favor  of  the 
latter  h3^pothesis.  But  in  such  a  matter,  where  no  third  person 
was  present,  the  statement  of  one  of  the  two  parties  concerned 
must  be  taken.  When  a  woman  whose  character  was  apparently 
without  blemish  (for  in  cross-examination  no  attempt  was  made 
to  call  her  reputation  in  question)  makes  a  definite  charge 
against  a  man  of  assaulting  her  under  circumstances  which 
permitted  of  such  an  assault,  the  law  could  only  send  the  case 
to  a  jury.  In  the  meantime,  the  unfortunate  surgeon's  assistant 
was  sent  to  prison. 

"When  the  case  came  to  be  tried,  a  large  number  of  medical 
men  of  repute  came  forward  voluntarily  to  aid  the  accused's 
defence,  and  did  this  quite  gratuitously.  The  chief  witness  for 
the  defence  was  Dr.  B.  W.  Richardson,  F.R.S.,  whose  celebrity 
is  world-wide.  As  is  well  known.  Dr.  Richardson  has  studied 
anaesthetics  very  carefully  and  for  many  years.  He  stated  that 
there  were  four  stages  or  degrees  in  which  chloroform  operated. 
The  first  stage  was  that  in  which  consciousness  was  not  lost ; 
there  was  resistance  and  a  desire  for  air.  In  the  second,  con- 
sciousness is  lost,  but  the  operation  is  impossible,  the  patient 
screaming,  often  without  provocation.  The  third  stage  is  that 
of  complete  unconsciousness,  and  where  all  rigidity  is  lost. 
This  is  the  stage  which  permits  of  operation.  In  his  opinion, 
the  patient  was  in  the  second  stage,  the  third  never  having 
been  reached.  He  stated  that,  in  his  own  experience,  he  had 
known  persons  in  this  second  stage  to  have  delusions  as  to  what 
had  taken  place  during  that  time.  He  related  a  number  of 
cases,  and  stated  that  the  fact  of  such  delusions  being  induced 
by  chloroform  was  one  of  the  earliest  objections  raised  to  its 
adoption.  He  related  one  case,  where  the  patient,  a  female, 
was  being  operated  upon  by  a  dentist,  and  alleged  that  the 
dentist  criminally  assaulted  her.  And  this  she  persisted  in, 
though  her  father,  her  mother,  Dr.  Richardson  and  the  den- 
tist's assistant  were  all  present  throughout  the  whole  time. 
She  persisted  in  her  conviction  long  after  the  effects  of  the 
chloroform  had  passed  away,  and  Dr.  Richardson  said  she  was 
probably  of  that   belief  still.     This   evidence  of  Dr.  Richard- 


LEGAL    RESPOXSIBILITY    OF    PHYSICIAXS.  525 

son's  was  corroborated  by  the  experience  of  Dr.  Hawk^by  of 
London,  and  by  Dr.  Saundby  and  Mr.  J.  R  West,  of  Birmino-. 
ham      The  judge  asked  the  jury  if  it  was  necessary  to  sum  up, 
and  they  rephed  it  was  unnecessary-they  were  already  agreed 
upon  a  verdict  of  acquittal.     Mr.  Justice  Hawkins  pointed  out 
that  such  a  verdict  would  not  be  the  slightest  imputation  upon 
the  absolute  sincerity  of  the  prosecutrix,  who.  no  doubt,  firmly 
believed  every  word  of  what  she  had  said.     He  then  congratu- 
lated  the   accused   upon  having   had  an   opportunitv  of  fully 
vindicating  himself  from   the  charge  preferred,  and 'said  that 
the  verdict  of  acquittal  did  not  mean  that  there  was  insufficient 
evidence,  but   that   the   accused   was   entirely  cleared   of  any 
rmputation   in  respect  to   the  charge   preferred  against  him. 
Ihere  could  be  no  doubt  the  prosecutrix  labored  under  a  delu- 
sion.    The  accused  was  then  discharged  from  custodv,  havino- 
been  in  prison  two  months  for  no  offence.     It  is  not  merely 
that  this  unfortunate  man  was  imprisoned  for  two  months  for 
an  imaginary  offence,  but  that  any  man  who  is  present  when  a 
woman  is  being  put  under  chloroform  is  liable  to  have  the  same 
charge  brought  against  him  that  gives  this  case  its  gravity  and 
importance. 

"Such   being   the   case,  it   becomes  necessarv  that   a  little 
more    should   be    known   amidst   the   profession,    as    well    as 
the  laity,  as  to  the  occurrence  of  erotic  sensations  in  women 
Ihe  subject  is   not   a   pleasant    one,    but    that  is   no   reason 
why  it  should  not  be  investigated.     If  it  is  a  fact,  and  there 
IS  no  doubt  about    this,  that  women,   when  bein-  put  under 
chloroform,  are   liable    to   those  erotic   sensations^hich  they 
experience    from   sexual   intercourse,  the   sooner   the   fact   is 
generally  known   the   better.     It   is  just   the   mysterv  which 
surrounds   such   facts  that  permits   such   a   monstrous    hard- 
ship as  that  mentioned  above   to  be  a  possibility  at  all.     Of 
course,  it  is  obvious  enough  to  any   one  that  it^is  a  delicate 
matter  to   inquire   into   the    subjective   sensations  of  women 
iiut  if  these  subjective  sensations  take  the  practical  form  of  a 
charge  of  rape,  two  months  in  jail  and  a  trial  bv  jurv,  they 
pass  from  the  domain  of  sentiment  and   enter  that  of  stern 
reality.     Few,  comparatively  few.  of  the   profession   seem   to 


526  ARTIFICIAL    ANESTHESIA. 

be  aware  that  women  are  subject  to  conditions  and  sensations 
identical  with  those  associated  with  the  sexual  act,  which  arise 
quite  subjectively  and  without  any  extrinsic  stimulus.      The 
delusion  of  St,   Catharine,  that  the   devil  visited  her  every 
night,  and  enjoyed  her  person  when  she  was  asleep,  and  could 
offer  no  resistance,  is  no  unique  experience,  but  one  common 
enough  to  women.      Every   one   familiar  with   asylum   work 
knows  that  a  certain  percentage  of  women  patients  have  this 
delusion,  among  others,  that  the  medical  superintendent  comes 
nightly  to  their  bed,  and  violates  their  person  during  sleep.    Of 
course  there  is  no  foundation  of  any  kind  for  such  delusions, 
except  the  subjective  sensations  of  the  woman  herself     How 
strongly  such  a  delusion,  however,  may  be  fixed  in  a  woman's 
mind  is  evidenced  by  the  case  related  by  Dr.  Richardson,  where  a 
woman  persisted  in  her  belief,  though  her  own  father  and  mother, 
as  well  as  others,  were  present,  and  where  such  an  assault  was 
physically  impossible.     Such  being  the  case,  it  behooves  every 
man  who  is  to  be  present  with  a  woman  when  she  is  to  be  placed 
under  chloroform  to  see  that  there  is  at  least  one  other  person 
present,  and  that,  too,  the  whole  time,  without  intermission,  dur- 
ing which  the  woman  is  under  the  influence  of  chloroform,  and 
that  such  other  precautions  be  taken  as  will  preclude  the  pos- 
sibility of  such  a  charge  being  raised.    That  Mrs.  Child  charged 
this  unlucky  man  in  good  faith  need  not  be  questioned  for  a 
moment.      She  was  far  from   being   hostile   to   him,  for  she 
offered  if  he  would  avow  his  guilt  and  leave  the  town  she  would 
forgive  him.     The  charge  was  not  pressed  from  any  rancorous 
spite ;  that  is  abundantly  clear.     But  it  is  equally  clear  that 
something  had  occurred  to  that  woman  which  she  interpreted 
into  the  sexual  act,  and  that  this  was  so  firmly  fixed  in  her  con- 
sciousness that  it  could  not  be  dislodged.    It  becomes  necessary, 
then,  that  the  subjective  sensations  of  women  should  be  inves- 
tigated,  and  made  the  subject  of  scientific  observations ;  and 
seeing  that  they  exist,  they  must  have  a  scientific  value ;  and 
that  no  prudishness  should  prevent  attempts  being   made  to 
ascertain  what  the  actual  facts  are,  and  what  is  their  interpreta- 
tion." 

The  following  is  the  experience  of  Dr.   N.   L.   Folsom,   of 
Portsmouth,  New  Hampshire,  in  the  same  line  : 


LEGAL    RESPONSIBILITY    OF    PHYSICIANS.  527 

"  In  J 854  a  clergyman's  sister  came  to  my  office  for  the  pur- 
pose of  taking  ether  and  having  a  tooth  extracted,  and  brought 
her  brother's  wife  with  her.  I  began  to  administer  the  ether 
to  the  patient,  and  whilst  renewing  it  she  got  away  from  me, 
and  seemed  alarmed  and  offended.  I  did  not  attempt  to  com- 
pel her  to  breathe  any  more  ether,  but  urged  her  to  take  it, 
and  so  also  did  her  brother's  wife,  but  she  would  take  no  more. 
She  had  the  impression,  so  her  brother  told  me,  that  I  attempted 
to  violate  her,  and  that  his  wife  assisted  me.  It  was  a  long 
time  afterward  before  she  would  fully  give  up  that  she  was 
mistaken  in  the  matter." 

We  are  almost  certain,  after  a  number  of  careful  experiments, 
that  chloroform  and  ether  can  be  administered  in  sleep,  so  as  to 
produce  the  first  stage  of  anaesthesia,  and  can  be  carried  to  full 
completion  or  total  unconsciousness.  Still,  this  is  rare  without 
disturbing  the  patient's  stomach,  causing  nausea,  or  irritation 
of  the  lungs,  with  risk  of  sudden  death,  by  its  dense  vapor, 
and  thus  rousing  him  or  her  to  consciousness,  or  a  condition  in 
which  the  patient  can  resist  its  influence  if  the  party  is  willing 
to  make  the  effort.  Another  important  point  is  that  loud  talk- 
ing or  handling,  even  in  some  cases  the  slightest  touch  or  pain 
in  any  way,  will  cause  the  patient  to  start  and  rouse  him  to 
resist.  In  the  case  of  ether,  the  patient  can  almost  always  see 
distinctly,  and  in  some  instances  is  able  to  talk  during  the  anaes- 
thetic state. 

Attention  has  been  directed  by  Dr.  J.  M.  Quimby,  of  Jersey 
City,  N.  J. ,  to  certain  facts  connected  with  the  use  and  abuse 
of  chloroform,  and  from  these  facts  inferences  have  been  derived 
which  may  be  interesting  and  instructive  to  the  profession,  con- 
firming the  power  of  the  physician  to  place  his  patient  under 
an  anaesthetic  while  asleep. 

He  states,  "  that  in  consequence  of  the  recent  murder  of  Po- 
liceman Smith,  in  Jersey  City,  while  he  and  his  wife  were  sup- 
posed to  be  asleep  in  bed,  his  wife  was  arrested  as  a.particeps 
criminis.  She  denied  the  charge,  and  asserted  that  she  had 
been  chloroformed  during  sleep,  and  therefore  was  innocent  of 
the  crime. 

"The  State  denied  this,  and  contended  that  it  was  impossible 


528  ARTIFICIAL    ANESTHESIA. 

for  her  to  have  been  chloroformed  in  that  way  ;  that  the  fumes 
of  the  chloroform  would  have  certainl^^  awakened  her  from  her 
natural  sleep,  and  therefore  she  must  have  known  who  the  mur- 
derer or  murderers  ivere. 

"  Here,  then,  as  will  be  seen,  arose  a  verj^  nice  and  important 
medico-legal  question,  viz. :  whether  a  person  could  be  chloro- 
formed whilst  in  natural  slumber  without  first  being  awakened, 
or,  in  other  words,  whether  the  application  of  chloroform, 
properly  given,  would  awaken  the  person  to  whom  it  was 
applied  ;  or,  could  such  person  pass  from  the  natural  to  an 
artificial  sleep  (or  chloroform  sleep)  without  being  aroused  by 
its  application  ? 

Mrs.  Smith  asserted  most  positively  that  she  was  chloro- 
formed while  she  was  asleep  in  bed  with  her  husband,  and 
knew  nothing  about  the  murder  until  she  awoke  in  a  bewil- 
dered condition,  feeling  the  cold  elbow  of  her  husband  pressing 
against  her  side.  It  may  be  stated  here  that  there  was  found 
in  the  room  of  the  murdered  man  a  bottle  partly  filled  with 
chloroform  and  a  folded  towel  with  bloody  finger-prints,  which 
Mrs.  Smith  asserted  was  upon  her  face  when  she  awoke.  She 
also  described  quite  accurately  the  taste,  smell  and  pungency 
of  chloroform. 

"Without  going  into  further  details,  the  counsel  for  Mrs. 
Smith  applied  to  me  to  know  if  it  were  possible  to  transfer  a 
person  from  a  natural  to  an  artificial  sleep  by  the  use  of  chlo- 
roform without  first  arousing  the  sleeper  from  his  natural  slum- 
ber. I  replied  that  I  had  never  attempted  the  application  of 
chloroform  to  a  person  while  in  a  natural  sleep,  and  that  books, 
as  far  as  I  knew,  were  silent  on  that  point ;  although  I  thought 
there  would  be  no  difficulty,  if  proper  care  were  taken  in  admin- 
istering the  chloroform,  in  transferring  a  person  from  the  natural 
to  an  artificial  sleep. 

"I  was  strongly  urged  on  the  part  of  Mrs.  Smith's  counsel, 
and  in  behalf  of  humanity  and  justice,  to  settle  by  experiment 
this  disputed  question.  To  accomplish  this  result  I  made  the 
following  experiments :  I  made  arrangements  with  Mr.  A.  to 
enter  his  room  in  an  hour  or  two  after  he  had  retired,  and  when 
he  was  asleep  apply  the  chloroform,  which  I  did  with  entire 


LEGAL    RESPONSIBILITY    OF    PHYSICIANS.  529 

success,  transferring  him  from  the  natural  to  the  chloroform 
sleep  without  arousing  him  from  his  natural  slumber.  I  used 
about  three  drachms  of  Squibb' s  chloroform,  and  occupied 
about  seven  minutes  in  putting  him  to  sleep.  The  second  case 
was  a  boy,  aged  13,  who  was  suffering  from  an  ingrowing  toe- 
nail. He  refused  to  allow  me  to  touch  him  with  knife  or  for- 
ceps without  etherizing  him,  and  when  I  attempted  to  apply 
the  ether  he  screamed  and  struggled  so  desperately  that  his 
mother  became  frightened,  and  asked  me  to  desist  from  giving 
him  ether.  In  this  dilemma  I  advised  the  mother  to  take  the 
boy  home  and  put  him  to  bed  with  a  light  supper,  and  I  would 
call  at  the  house  between  nine  and  ten  o'clock  that  evening, 
give  him  a  little  chloroform,  and  remove  the  nail  without  the 
boy  knowing  anything  about  it. 

"I  called  at  the  time  agreed  upon,  with  my  friend,  Dr. 
Cahill,  and  found  the  boy  quietly  sleeping.  I  applied  the  chlo- 
roform, divided  the  nail  in  the  centre,  and  removed  the  two 
segments  by  the  application  of  forceps  without  awakening  the 
patient  or  his  having  any  knowledge  of  the  operation  until  next 
morning,  when  he  awoke,  and,  discovering  the  condition  of  his 
foot,  remarked  that  had  he  known  '  it  would  not  hurt  any  more 
than  that  he  would  have  had  it  taken  out  at  the  office,  and  was 
ashamed  that  he  had  made  such  a  fuss  about  it.'  " 

"Case  No.  3  was  a  boy,  aged  10,  who  was  brought  to  my 
office  suffering  from  a  swelling  over  the  lower  jaw,  which  proved 
to  be  an  abscess  due  to  decayed  teeth  ;  but  the  boy  would  not 
let  me  come  near  him  with  either  lancet  or  forceps  ;  so,  as  in 
previous  cases,  I  advised  his  mother  to  take  him  home  and  send 
him  to  bed  with  a  light  supper,  and  that  I  would  call  at  the 
house  after  he  got  asleep,  administer  the  chloroform,  open  the 
abscess,  extract  the  teeth,  and  he  would  know  nothing  about 
it ;  all  of  which  I  did  without  arousing  the  boy. 

"I  remained  with  the  patient  about  one  hour  after  the  ope- 
ration, to  attend  to  any  haemorrhage  that  might  occur,  and  to 
observe  if  any  change  would  take  place  when  he  would  pass 
from  his  artificial  to  his  natural  slumber  again. 

"Finding  there  was  no  change  in  that  time  I  left,  requesting 
the  parents  to  watch  him  and  let  me  know  exactly  at  what  hour 
he  awoke. 


530  ARTIFICIAL    ANAESTHESIA. 

"  When  I  called  next  morning,  they  reported  that  he  awoke 
at  six  o'clock,  exclaiming,  '  I  must  have  swallowed  my  teeth, 
for  they  are  both  gone ! '  " 

"Beware  of  Chloroforming  Women  without  an  At- 
tendant I — At  Oakland,  Cal. ,  during  July,  1880,  a  bank  teller, 
named  E.  F.  Schroeder,  killed  Dr.  Albert  Lefevre,  a  prominent 
dentist  of  that  place.  It  appears  that  Mrs.  Schroeder  went  to 
the  train  on  the  day  of  the  shooting  to  meet  her  husband. 
Mrs.  Schroeder  told  him,  that  on  the  Saturday  previous,  while 
under  the  influence  of  chloroform  in  Dr.  Lefevre' s  office,  the 
dentist  made  a  felonious  assault  upon  her.  Schroeder  at  once 
proceeded  to  Dr.  Lefevre' s  office  and  committed  the  tragedy. 
It  is  believed  that  Mrs.  Schroeder' s  charge  against  the  dentist 
is  purely  illusory.  Such  hallucinations  are  not  uncommon  after 
chloroform  administrations.  Some  remarkable  cases  exist  where 
hallucinations  of  this  nature  have  taken  the  form  of  absolute 
conviction  in  the  minds  of  persons  laboring  under  them,  al- 
though there  exists  abundant  evidence  to  prove  that  this  con- 
viction was  utterly  unfounded.  The  coroner's  jury  rendered  a 
verdict  charging  Schroeder  with  murder.  We  know  of  an  in- 
stance in  which  the  presence  of  a  third  party  saved  a  like  im- 
putation against  the  character  of  an  innocent  practitioner. 
The  lady  herself  beyond  reproach  still  had  such  an  illusion  after 
recovering  from  the  administration  of  the  chloroform." 

"  Prosecution  of  a  Dentist. — At  the  Manchester  Assizes, 
before  Mr.  Justice  Day,  an  action  was  brought  against  Mr. 
James  Jackson,  a  dentist,  of  Burnley,  in  which  the  plaintiff, 
Mr.  Robert  Jackson,  farmer,  sought  to  recover  damages  for  the 
alleged  seduction  of  his  daughter  while  under  the  influence  of 
nitrous  oxide.  There  was  also  a  cross-action  for  slander  brought 
against  the  plaintiff.     The  trial  occupied  nearly  three  days. 

"His  Lordship,  in  summing  up,  said  the  one  substantial 
issue  for  the  jury  was,  did  James  Jackson,  the  dentist,  or  did 
he  not,  administer  gas  or  some  narcotic  to  the  young  woman, 
Margaret  Ann  Jackson,  and  did  he,  while  she  was  under  the 
influence  of  some  anaesthetic,  criminally  assault  her?  That 
was  the  question  they  had  to  determine,  and  it  was  a  question 
of  the  very  gravest  moment.     The  consequences  to  the  one  side 


CHLOROFORM ITS    ACTION    AS    A    POISON.        531. 

or  the  other  must  necessarily  be  of  the  most  serious  character. 
The  charge  which  was  made  against  the  dentist  was  one  of 
assault  under  circumstances  of  the  most  aggravated  and  nefa- 
rious nature.  The  charge,  on  the  other  hand,  of  which  the 
woman  would  be  guilty,  if  she  had  made  a  false  accusation,  was 
one  of  the  most  wicked,  odious  and  vile  that  could  be  brought 
by  one  human  being  against  another.  The  case  was  one  of  a 
most  extraordinary  character,  and  one  which,  he  was  happy  to 
think,  was  very  rarely  raised  in  a  court  of  justice.  It  was  one 
which  demanded  at  the  hands  of  the  jury,  as  he  knew  it  would 
most  assuredly  receive,  their  deepest  and  most  anxious  atten- 
tion, so  that  to  the  utmost  of  their  ability  they  might  do  justice 
between  the  parties.  He  did  not  hesitate  to  say  that  the  ques- 
tion was  of  an  extremely  difficult  character,  but  it  was  one  which 
he  was  confident  the  jury  would,  using  their  own  good  sense, 
solve  to  their  thorough  satisfaction  ;  and  if  they  did  solve  it  to 
their  satisfaction,  it  should  be  satisfactory  to  all  well-minded 
people.  He  would  say  nothing  about  damages,  because  it  was 
unnecessary.  The  parties  probably  were  none  of  them  in  a  po- 
sition to  pay  damages.  That,  however,  was  utterly  unimpor- 
tant, and  should  not  affect  the  amount  of  damages.  It  was 
unnecessary  for  him  to  say  a  word  about  damages,  because  he 
should  not  venture  to  put  any  limit  upon  the  damages  which 
they  might  award  to  the  one  side  or  the  other. 

"  The  jurj^  retired  to  consult  on  the  case,  and  after  deliberat- 
ing for  three  hours  returned  to  court  and  stated  that  there  was 
no  possibility  of  their  coming  to  an  agreement.  The  judge 
thereupon  discharged  them. ' ' 

Chloroform — Its  Action  as  a  Poison. 

Chloroform  is  an  irritating  poison.  In  a  case  quoted  by 
Taylor,  an  individual  swallowed  four  ounces.  He  was  able 
to  walk  a  considerable  distance  after  taking  this  large  dose, 
but  subsequently  fell  into  a  state  of  coma.  The  pupils  were 
dilated,  the  breathing  was  stertorous,  the  skin  cold,  pulse  imper- 
ceptible, and  there  were  general  convulsions.  He  recovered  in 
five  dsija.  A  second  case  reported,  swallowed  nearly  two  ounces 
and  recovered,  and  a  third  swallowed  two  ounces,  but  he  died 


532  ARTIFICIAL    ANESTHESIA. 

in  six  hours  afterwards.  In  this  case  the  pupils  were  fully 
dilated,  the  breathing  was  stertorous,  and  the  skin  covered  with 
a  cold  perspiration.  On  inspection,  the  lungs  were  found  much 
■engorged  with  blood,  and  there  were  some  apoplectic  effusions 
in  these  organs.  The  stomach  was  slight]}^  inflamed  in  patches 
and  the  mucous  membrane  was  softened.  * 

A  physician,  aet.  57,  swallowed  three  ounces  of  chloroform. 
He  immediately  began  to  stagger,  as  if  intoxicated,  vomited, 
sank  into  a  deep  stupor,  and  was  in  a  state  of  complete 
anaesthesia.  His  skin  was  pale  and  tolerably  warm ;  the 
muscles  were  relaxed,  the  breathing  short,  and  the  action  of 
the  heart  weak  and  intermittent.  In  about  fourteen  hours  sen- 
sibihty  returned.  Acute  gastritis  ensued,  with  rapid  collapse, 
and  proved  fatal  in  twenty-nine  hours  from  the  time  the  chloro- 
form was  taken. t 

Treatment. — In  poisoning  from  liquid  chloroform,  the 
stomach-pump  and  emetic  should  be  resorted  to.  If  evidence 
of  suspension  of  the  action  of  the  heart  (syncope)  exists, 
there  should  be  a  free  exposure  of  the  face  to  a  current  of 
air,  compression  of  the  chest  and  artificial  respiration,  warm 
appHcations  to  the  chest,  with  an  inversion  of  the  body,  ac- 
tive friction  and  stimuli  externally  and  by  the  rectum.  The 
poles  of  a  galvanic  battery,  applied  to  the  chest  and  side  of 
the  neck,  with  sponges  dipped  in  hot  water,  should  be  used. 
Solution  of  ammonia  in  water  has  been  found  useful  when  in- 
jected hypodermically,  and  strychnia,  in  the  same  way,  to  act 
upon  the  respiration.  Aromatic  spirits  of  ammonia  must  be 
given  with  water,  and  great  care  taken  of  gastritis  and  disturb- 
ance of  the  liver,  which  are  apt  to  follow  in  the  convalescence 
of  the  patient. 

The  Chloroform  Habit,  or  Chloroform  by  the 

Mouth. 

I  have  received  the  following  letter  from  a  friend  on  the 
chloroform  habit,  and  sent  him  my  reply : 

*  American  Journal  Medical  Sciences,  October,  1866,  page  571. 
t  American  Journal  Medical  Sciences,  January,  1870,  page  276. 


THE    CHLOROFORM    HABIT.  533 

"  Shelbourne,  Mass.,  May  29,  1890. 
"My  pear  Doctor  : 

"  What  I  wish  to  know  is  whether  chloroform,  given  by  the 
mouth,  is  good  and  sa/e  practice.  I  have  given  it  several  times 
that  way,  and  always  had  good  results.  There  is  a  doctor  in 
this  town  who  is  a  chloroform  inebriate,  and  I  have  known  him 
to  take  thirty -four  ounces  (34  o)  of  chloroform  in  twenty-three 
hours.  He  always  gave  his  patients  chloroform  for  everything,, 
and  usually  gave  it  by  the  mouth.  For  a  small  operation  he 
gave  a  teaspoonful  in  a  glass  of  wine,  and  told  them  to  breathe 
rapidly  through  the  mouth.  It  acts  quickly  and  very  nicely. 
I  have  never  seen  any  authority  for  administering  it  hj  the 
mouth,  and  have  wondered  lately  if  it  were  safe  practice.  If 
you  should  find  a  leisure  moment  some  day,  should  be  pleased 
to  know  your  views  on  the  subject.  If  safe,  I  prefer  giving  it 
that  way  in  many  cases.         Yours, 

"H.  H.  Flagg." 

The  writer's  answer  was,  that  he  considered  chloroform  given 
by  the  mouth  neither  a  safe  nor  judicious  practice,  as  death 
may  follow  by  paralysis  of  the  heart.  The  fatal  dose  is  given 
in  recent  works  in  the  table  of  poisons  as  5j  (see  GoidcVs  Dic- 
tionary)^ the  treatment  of  which  is  as  follows  :  Draw  the  tongue 
forward  for  air,  use  artificial  respiration,  faradic  current,  hot 
and  cold  douche,  amyl  nitrite. 

The  chloroform  habit  is  usually  the  result  of  its  secret  use, 
and  is  considered  most  degrading  to  both  body  and  mind  (see 
Chloroform  as  a  Poison,  page  531). 

Transitory  mental  and  muscular  excitement,  similar  to  that 
referred  to  when  dealing  with  the  after-effects  of  ether,  may 
occur  in  hysterical  and  neurotic  subjects.  Delirium  lasting 
three  days  has  been  recorded.*  Loss  of  speechf  (attributed  to 
cerebral  haemorrhage)  has  also  been  supervened  after  chloro- 
formization.    Persons  who  have  had  maniacal  attacks  before  the 

*  See  an  interesting  pamphlet,  "  Ether  as  an  Anaesthetic,"  by  Josiah 
de  Zouche,  M.D.,  of  Otago.  in  which  delirium  lasting  three  days  in  a 
boy  of  14  was  met  with  after  chloroform-inhalation. 

t  Lancet,  vol.  i.,  1870,  p.  553.  Chloroform  was  given  for  a  tooth 
extraction.    The  aphasia  lasted  five  weeks. 


534  ARTIFICIAL    ANESTHESIA. 

administration  of  chloroform,  have  been  known  to  suffer  from  a 
recurrence  of  their  mental  disorder  after  the  use  of  this  anaes- 
thetic* 

Hypnotic  Anaesthesia  and  its  Analogous  States 
in  their  Various  Aspects. 

While  spending  the  winter  in  France  (1893)  there  was  placed 
in  my  hands,  by  a  scientific  layman,  the  work  of  "  La  Tourette  " 
on  Hypnotism.  It  was  shortly  after  the  time  that  there  had 
occurred  a  newspaper  controversy  between  a  distinguished  medi- 
cal editor  of  London  and  an  ancient  physician  of  Paris,  the 
latter  of  whom  had  given  unusual  prominence  in  his  practice 
to  the  agency  of  hypnotism,  while  the  former,  after  experiment- 
ing with  a  number  of  his  cases,  believed  the  doctor  had  been  de- 
ceived in  them. 

Having,  in  my  previous  edition,  brought  forward  this  agency 
as  a  means  of  producing  a  certain  form  of  anaesthesia,  which 
can  be  employed  in  certain  rare  surgical  operations,  I  have  en- 
deavored to  improve  the  opportunity  to  study  the  subject  more 
in  detail,  especially  in  its  anaesthetic  and  medico-legal  aspect, 
so  as  to  make  my  work  more  useful  to  my  medical,  dental,  and 
scientific  confreres.  Hypnotism  is  still  being  tried  in  the 
alembic  of  the  medical  and  scientific  mind,  its  friends  still  hold- 
ing to  certain  results,  obtained  by  the  most  carefully  conducted 
experiments,  while  others  give  it  a  very  high  estimate  far  beyond 
what  it  deserves  as  a  nerve  agent.  Yet,  from  what  has  been 
seen,  we  must  not  be  too  skeptical.  The  late  Prof.  Charcot 
answers  the  skeptics  as  follows:  "In  presence  of  the  evidence 
of  facts  presented,  scientific  skepticism  is  only  an  arbitrary 
skepticism." 

No  one  with  average  intelligence  can  help  being  impressed 
with  the  fact  that  certain  hysterical  individuals  can  be  placed  in 
a  so-called  hypnotic  condition  or  state  by  individuals,  or  by  con- 
stant gazing  intently,  for  a  given  time,  at  a  bright  object,  like 
metal,  brought  near  to  the  eyes  of  those  susceptible.  While  the 
individual  is  in  this  condition,  certain  phenomena  can  be  pro- 
duced. 

■«  See  Savage,  Brit.  Med.  Journ.,  Dec.  3,  1887,  p.  1199. 


THERAPEUTIC    HYPNOTISM.  535 

The  following  is  an  abstract  of  the  histon-  of  the  hj^pnotic 
state.  Propositions  of  ]Mesmer  (Animal  Magnetism)  1779. 
The  theoiy  of  universal  magnetic  attraction.  The  report  of  the 
secret  Royal  Commission  demanded  of  Mcsmer,  by  Louis  XTl. , 
describing  the  various  symptoms  produced  and  some  important 
medico-legal  facts.  In  1784  Pa\'seger  discovered  how  to  pro- 
duce artificial  somnambulism,  and  described  successful  magnet- 
ism, ls2].  Discussions  of  the  Academies  of  Paris  by  Du  Potet 
Foessa  and  the  Report  of  Husson,  1825-1834.  The  prize  of 
Beerdin,  1837-1840. 

The  discussion  in  the  Academie  of  Medicine  of  its  medico- 
legal importance  and  the  institution  of  the  Penal  Code.  Then 
follows  the  Xeuryphologie  of  "Braid  ;"  but  no  great  scientific 
progress  was  made  until  1878,  when  "  Charcot  "  and  "  Brouar- 
del  "  took  up  the  subject  and  made  long,  careful,  and  elaborate 
experiments,  and  came  to  the  following  conclusions  as  to  its 
medical  application  and  therapeutic  uses. 

Hypnotism  as  an  Antestlietie. 

Hypnotism  (from  hypnos)  is  the  production  of  sleep  by  what 
was  generally  known  as  animal  magnetism.  Only  certain  in- 
dividuals are  susceptible  to  its  influence.  The  person  who 
operates  has,  in  our  opinion,  great  will  power  over  the  indi- 
vidual operated  upon.  The  patient  hj-pnotized  is  not  absolutely 
insensible,  but  operations  of  a  trifling  nature  can  be  performed 
without  apparent  pain. 

It  is  stated  by  La  Tourette  that  excellent  effects  have  resulted 
in  the  treatment  of  accidents  and  complications,  from  the  use  of 
hypnotism,  in  certain  forms  of  contractions  of  muscles  and 
paralysis ;  also  in  mental  alienation  and  manifestations  of 
hysterical  delirium. 

Therapeutic  Hj^pnotisni. 

It  is  quite  well  known,  according  to  "La  Tourette,"  that  a 
course  of  action  suggested  to  a  hypnotized  person  is  followed 
irresistibly  and  unconsciously^  by  that  person  after,  as  well  as 
during,  the  hypiiotic  state.  Upon  this  is  based  the  medical  ap- 
plication of  hypnotism.  If  a  subject  can  be  made  to  carry 
out  useless,  eccentric,  or,  in  some  cases  that  have  become  known, 


536  ARTIFICIAL    ANESTHESIA. 

even  criminal  suggestions,  without  his  own  knowledge  of  the 
character  of  the  cause  of  his  action,  why,  ask  the  scientific  ex- 
perimenters, may  not  the  same  cerebral  mechanism  be  brought 
into  play  to  influence  the  physical  state  of  persons  suffering  from 
certain  kinds  of  disorders?  The  influence  of  the  mind  and  the 
imaginative  faculties  on  the  body  in  such  cases  has  long  been 
known  ;  and  it  is  maintained  that  this  kind  of  suggestion  does 
not  differ,  in  reality,  from  that  of  the  hypnotic  state.  What- 
ever may  be  the  cause  which  excites  the  nervous  centres  of 
the  brain  to  intervene  in  order  usefully  to  modify  the  organic 
function  of  the  body,  the  process,  say  these  investigators,  is  the 
same. 

Reports  submitted  at  the  late  congress  in  Paris,  the  treatment 
of  invalids  in  this  manner  already  shows  some  remarkable  re- 
sults. Two  physicians  of  Amsterdam  told  of  414  cases  they 
had  treated  by  hypnotism.  Of  these  100  were  fully  cured,  in 
98  there  was  a  noticeable  improvement,  in  92  a  slight  one,  and 
in  only  71  were  there  no  results ;  58  cases  were  not  followed. 
These  cases  included  organic  maladies  of  the  nervous  system, 
mental  diseases,  and  neuralgia,  besides  others  not  directly  con- 
nected with  the  nervous  system.  The  treatment  of  the  insane 
was  especially  discussed  by  others,  and  here,  too,  success  has 
been  obtained  in  some  cases,  though  the  difficulties  are  far 
greater  than  in  physical  maladies.  A  curious  and  interesting 
report  was  presented  by  one  of  the  physicians  in  regard  to  his 
experiments  with  children,  whom  he  found  easier  to  influence 
by  suggestion  than  their  elders.  In  this  he  submitted  as  a  proven 
conclusion  the  value  of  hj^pnotic  suggestion  as  "an  excellent 
auxiliary  in  the  education  of  vicious  or  degenerate  children,"  it 
being  "  especially  efl&cient  in  reacting  against  vicious  instincts, 
habitual  lying,  cruelty,  theft,  and  inveterate  idleness. "  This  is, 
perhaps,  one  of  the  most  startling  assurances  we  are  given  of 
the  powers  of  hypnotism  in  the  hands  of  competent  men  ;  and 
such  results,  already  attained,  seem  to  point  to  possibilities  of 
great  importance  in  the  further  development  of  this  study. 

There  is  another  side  to  all  this,  however,  which  the  congress 
in  Paris  did  not  fail  to  consider.  That  is  the  danger  of  the 
abuse  and  the  irresponsible  use  of  the  hypnotic  phenomena. 


THERAPEUTIC    HYPNOTISM.  537 

Trick  performances  of  travelling  quacks  are  common,  even  in 
this  couiitr}'.  and  the.y  are  to  be  considered  not  onlj-as  a  vulgari- 
zation of  the  science,  but  a  danger  to  health  and  morals.  Equal 
danger  rests  in  opportunities  that  hypnotism  affords  the  crimi- 
nally inclined,  which  can  easily  be  seen  are  numerous.  A  hyp- 
notized subject  is  really  made  the  instrument  of  vengeance  or 
cupidity,  quite  unconsciousl}''  to  himself,  after  emerging  from 
the  hypnotic  state ;  and  not  only  that,  but  may  be  made  to  take 
upon  himself  the  sole  blame.  All  these  perils,  it  may  be,  will 
some  time  have  to  be  guarded  against,  though  knowledge  of  the 
subject  is  j^et  too  restricted  to  make  them  alarming.  But  if  this 
be  so,  it  will  be  only  one  more  instance,  so  many  of  which 
modern  times  can  show,  in  which  things  of  yalue  to  humanity 
are  perverted  to  damaging  uses.  Of  course,  this  unfortunate 
fact  will  not  put  an  end  to  the  investigations  which  promise  so 
much  of  value  ;  the  advances  made  in  this  curious  and,  in  its 
scientific  application,  so  recent  branch  of  scientific  studj"  will 
be  watched  with  great  interest. 

Report  of  the  Coniniittee  Appointed  hj  the  British 

31edical  Association  to  Investigate  the  Xatiu'e 

of  the  Phenomena  of  Hypnotism — Its  Value 

as  a  Therapeutic  Agent,  and  the 

Propriety  of  Using'  It. 

The  Committee,  having  completed  such  investigation  of  hyp- 
notism as  time  has  permitted,  have  to  report  that  they  have 
satisfied  themselves  of  the  genuineness  of  the  hypnotic  state. 
No  phenomena  which  have  come  under  their  observation,  how- 
ever, lend  support  to  the  theorj''  of  "  animal  magnetism." 

Test  experiments,  which  have  been  carried  out  by  members 
of  the  Committee,  have  shown  that  this  condition  is  attended 
by  mental  and  physical  phenomena,  and  that  these  difi"er  widely 
in  different  cases. 

Among  the  mental  phenomena  are  altered  consciousness, 
temporary  limitation  of  will  power,  increased  receptivity  of 
suggestion  from  without,  sometimes  to  the  extent  of  pro- 
ducing passing  delusions,  illusions  and  hallucinations,  an  ex- 

35 


538  ARTIFICIAL    ANESTHESIA. 

alted  condition   of   the   attention   and   post-hypnotic   sugges- 
tions. 

Among  the  physical  phenomena  are  vascular  changes  (such 
as  flushing  of  the  face  and  altered  pulse  rate),  deepening  of  the 
respirations,  increased  frequency  of  deglutition,  slight  muscular 
tremors,  inability  to  control  suggested  movements,  altered  mus- 
cular sense,  anaesthesia,  modified  power  of  muscular  contrac- 
tion, catalepsy  and  rigidity,  often  intense.  It  must,  however, 
be  understood  that  all  these  mental  and  physical  phenomena  are 
rarely  present  in  any  one  case.  The  Committee  takes  this  op- 
portunity of  pointing  out  that  the  term  hypnotism  is  somewhat 
misleading,  inasmuch  as  sleep,  as  ordinarily  understood,  is  not 
necessarily  present. 

The  Committee  is  of  the  opinion  that,  as  a  therapeutic 
agent,  hypnotism  is  frequently  effective  in  relieving  pain,  pro- 
curing sleep  and  alleviating  many  functional  ailments.  As  to 
its  permanent  efiicacy  in  the  treatment  of  drunkenness,  the 
evidence  before  the  Committee  is  encouraging,  but  not  conclu- 
sive. 

Dangers  in  the  use  of  hypnotism  may  arise  from  want  of 
knowledge,  carelessness  or  intentional  abuse,  or  from  the  too 
continuous  repetition  of  suggestions  in  unsuitable  cases. 

The  Committee  is  of  opinion  that,  when  used  for  therapeu- 
tic purposes,  its  employment  should  be  confined  to  qualified 
medical  men,  and  that  under  no  circumstances  should  female 
patients  be  hypnotized  except  in  the  presence  of  a  relative  or  a 
person  of  their  own  sex. 

In  conclusion,  the  Committee  desires  to  express  its  strong 
disapprobation  of  public  exhibitions  of  hypnotic  phenomena, 
and  hopes  that  some  legal  restriction  will  be  placed  upon  them. 

F.  Needham,  Chairman. 
T.  OuTTERSON  Wood,  Hon.  Sec. 

July,  1892. 


INDEX. 


ACETIC  Ether,  aneesthetic  prop- 
erties, by  Dr.  H.  C.  Wood.  200. 
A.  C.  E.  Mixture,  353;  accideuts 
with,  351 ;  use  of  in  old  per- 
sons with  rigid  chest,  514; 
iu  extreme  obesity,  514;  E. 
C.  Mixture,  352. 
Acetauilide,  use  of,  in  vomiting,    i 

496;  in  extreme  obesity,  514. 
Acid,  carbolic,  476  ;  trichloracetic, 

new  test  for  albumen,  483. 
Action  of  chloroform,  35,  254,261, 
275,  313;  cocaine,  387;  ether, 
31,  149. 
Acupuncture    with     cocaine   by 
Baunschiedt's  method,  372.^ 
Administration    of    cocaine,    37, 
386 :  chloroform,  243 ;  ether, 
149. 
After-effects  of  anasthetic  chlo- 
roform, 288;    nitrous   oxide, 
107,  108,  109. 
After-treatment  of  alcohol,  147; 
cocaine.  393;  chloroform,  261- 
273  ;  ether,  152 ;  nitrous  ox- 
ide, physiological  action,  78, 
84,  93,  107. 
Albumen,  examination  for,  317, 

151 ;  new  test,  483. 
Alcobolists,  the  danger  of  giving 

an  ansesthetic  to,  250. 
Alcohols,  absolute,  135;  alcohol- 
ism, 147 ;  different  kinds  of, 
135 :  medico-legal  aspect,  146 ; 
physiological  action,  136-141 ; 
influences    on    kidney    and 
liver,    141;    strychnine    and 
solution  of  a  salt  of  gold  in 
chronic  alcoholism,  147;  tox- 
icology of,  147;   use  in  dis- 
eases and  as  food,  136. 
Aldehyde,  207,  208. 
Allis.   Dr.   O.   H.,   157;    inhaler, 
158,  159. 


Amvlene,  its  vapor,  206;  death 
'from,  207. 

Amory,  Dr.  Boston,  experiments 
on  animals  with  nitrous  ox- 
ide, 79. 

Amyl  nitrite,  291,  397,  514. 

Anaemia,  danger  from  in  anaes- 
thesia from  nitrous  oxide,  79. 

Analgesics.  479. 

AnEesthetics.  geographical  distri- 
bution of  fatalities,  2.52 ;  value 
in  disease— which  to  avoid 
and  those  to  employ  509. 

Aphonia,  nervous,  treatment  of, 
508. 

Aristol,  484. 

BEDDOES,  Thomas.  Pneumatic 
Medical  Institution,  27. 

Beer  drinkers,  hypertrophied 
kidneys,  liver,  etc.,  144,  145. 

Benzol,  486. 

Bernard,  Claude,  experiments  on 
angesthesia  produced  by  in- 
troducing the  tube  through 
the  nose  into  the  lower 
pharynx,  184;  on  the  action 
of  cocaine  on  cerebral  circu- 
lation, 397;  the  action  of 
chloroform  upon  nerve  cells, 
260. 

Bert,  M.  Paul,  use  of  nitrous  ox- 
ide and  oxygen,  96. 

Bichloride  of  methylene,  201; 
discovery  and.  introduction, 
202 ;  deaths  from,  203. 

Bigelow,  Dr.  H.  T.,  use  of  rhigo- 
lene,  456. 

Blood,  actual  changes  produced 
by  anaesthetics,  36;  after 
death  by  nitrous  oxide,  70; 
appearance  of  frogs  in  direct 
contact  by  chloroform,  73; 
anaesthetics    in    contact,   74, 


540 


INDEX. 


75;  arterial,  becoming  deoxi- 
dized. 78;  examinatiou  of 
by  Drs.  McQuillen,  Eichard- 
son,  Thomas,  C.  S.  Turubull 
and  author,  79,  80 ;  pressure 
under  nitrous  oxide,  87,  88, 
496;  on  alteration  by  anes- 
thetic agents,  especially 
nitrous  oxide,  etc.,  92. 

Bonwill's  method  of  producing 
an?3sthesia,  372. 

Boston  monument  to  commemo- 
rate the  discovery  of  anaes- 
thesia by  ether,  37. 

Bowditch  and  Minot,  researches, 
157. 

Brackett,  Dr.  C.  A.,  of  Dental 
Medicine  (D.M.D.),  prolonged 
anaesthesia  from  nitrous  ox- 
ide in  major  operations  in 
surgery,  94. 

Brandy,  improper  use  of,  in  opera- 
tions, 139  ;  in  diphtheria,  127. 

British  Medical  Association,  1892, 
reports  of  aneesthetics,  537  ; 
hypnotism,  538. 

Bright's  disease,  cases  of  injury 
from  anaesthetics  in  chronic, 
225;  nitrous  oxide,  effects  on, 
80;  ether,  action  on,  155. 

Bradford,  John  Eoss,  B.  Sc,  Uni- 
versity physiological  labora- 
tory, experiments  upon  the 
brain  and  spinal  cord,  82. 

Bromide  ethylene  (not  ethylbro- 
mide),  204. 

Bromide  ethel,  hydrobromic 
ether  or  bromide  of  ethyl, 
227;  history  of,  227;  impuri- 
ties, 235:  mode  of  employ- 
ment, 230 ;  mode  of  prepara- 
tion, 227;  mixtures  of  and 
their  dangers,  233-235;  use 
of  in  Germany,  238 ;  value  of 
in  obstetrics,  236,  237. 

Bromoform  as  an  anaesthetic, 
205 ;  use  in  treatment  of 
whooping-cough,  205 ;  heart 
depressant,  physiological  ef- 
fects, by  Prof.  Eeichert  and 
Dr.  Kriger,  205, 

Bruntou,  criticism  of  Drs.  Gas- 
kill  and  Shore,  280,  281. 

Buren,  Dr.  Henry,  Chicago,  case 


of  death  from  mixture  of 
ether  and  chloroform  by, 
361. 

Burnet,  James  B.,  A.M.,  M.D., 
Newark,  N.  J.,  use  of  Jiitrous 
oxide  in  old  pleuritic  adhe- 
sions, acute  irritation,  pain- 
ful catarrhal  bronchitis,  etc., 
125. 

Butyl  chloride,  cardiac  pulsation 
becoming  weaker  and  finally 
extinguished,  caused  by,  206. 

Buxton,  Dr.  Dudley,  experiments 
on  physical  changes  in  the 
condition  of  the  brain  and 
spinal  cord  with  Prof.  Hors- 
ley,  80 ;  action  of  nitrous 
oxide  on  the  heart,  86;  re- 
viewing nitrous  oxide  exper- 
iments, 88;  on  the  kidneys, 
89 ;  respiratory  rhythm,  89 ;' 
administration  of  nitrous 
oxide  to  children,  by.  111. 

CAFFEINE,  461. 

Canadol,  462. 

Carbon,  dichlorine  or  chloric 
ether,  204. 

Cardiac  failure,  definition  of 
treatment,  494-498. 

Catarrh,  the  use  of  cocaine  in 
acute,  426. 

Carter,  Dr.  Wm.  S.,  experiments 
with  Prof.  Wood  on  tissue 
changes  after  death  from 
ether,  186,  187. 

Cerna,  Dr.  D.,  and  Dr.  Wood,  ex- 
periments with  nitrous  oxide, 
105. 

Changes  of  tissue  found  in  cases 
of  death  after  ether,  186. 

Chiene,  Prof.  John,  clinic  in 
University,  Edinburgh,  me- 
thod of  administering  chlo- 
roform, 248,  249. 

Children,  use  of  nitrous  oxide 
and  oxygen  by  Dr.  Hewitt 
for,  103. 

Chilblain,  use  of  cocaine  in  treat- 
ment of,  425. 

Chloric  ether.  35, 

Chloralamid,  486. 

Cholera,  treatment  by  ether  and 
camphor,  195. 


INDEX. 


541 


Circulation,  action  of  ether  upon, 
155;  action  of  chloroform, 
531. 

Chloroform,  administration  of, 
•243.  247,  252.  253  :  to  alcohol- 
ists,  250;  antidotes  for  poison- 
ing by.  532.  533;  action  of,  248; 
deaths  from,  293;  and  deaths 
from  after-eftects.  318;  dan- 
gers. 248 ;  deaths  from  in 
Reading,  Pa..  306;  deaths 
from  in  dental  operations, 
329;  dangers  in  dental  sur- 
gery, 275 ;  dangers  in  treat- 
ment of.  and  signs  of.  duty 
of  assistants  in,  248,  249  ;  dis- 
covery of,  35:  inhalers  for. 
183,  244-247.  253,  506  ;  mode 
of  administration,  248  ;  mode 
of  preparation.  239 :  or  ether, 
which  (?),  211 ;  the  pupil  as  a 
guide,  259;  signs  and  treat- 
ment of  dangers.  261 ;  the 
pulse  during,  296;  Eauke's 
experiments,  260 ;  Scotch 
method,  248;  stimulation, 
248:  toxicological  effects  of, 
261. 

Clover  small  portable  inhaler, 
167 ;  patients  ceasing  to 
breathe  and  how  to  start 
them  again.  168. 

Coca  plant  leaves,  preparations, 
etc.,  use  in  treatment  of  dis- 
ease, 384;  use  of  wine  of, 
made  from  the  fresh  dried 
leaves,  also  cocaine.  385. 

Coca  leaves,  active  principle  of, 
386;  therapeutic  uses  of.  336. 

Cocaine,  experiments  with,  390, 
391 ;  action  on  nerve  centres, 
393;  action  on  the  animal 
system,  289;  antagonism  to 
ether  and  chloroform,  398; 
chemical  tests.  388,  389;  in 
diseases  of  the  ear,  415 :  in 
diseases  of  the  eye,  412,  416; 
in  diseases  of  the  nose,  teeth, 
throat,  412.  415;  inebria- 
tion and  habit,  treatment  of, 
395-396 ;  inebriety,  treat- 
ment of,  396;  its  impurities 
and  instability,  388;  maxi- 
mum dose  of,  421 ;    number 


of  deaths  from,  416 ;  no  mor- 
bid changes  in.  420 ;  on  sight, 
hearing  and  brain,  394;  poi- 
soning from,  420:  prior  to 
and  during  aufesthesia,  411; 
in  circumorbital  pain,  treat- 
ment by.  432 ;  spray  of  petro- 
latum ether  with,  412  ;  use  on 
nasal  mucous  membrane  prior 
to  and  during  anaesthesia, 
411 ;  was  it  poisoning  by  (?), 
413. 

Chorea,  use  of  nitrous  oxide  in 
treatment  of.  121,  511. 

Cold  in  the  head,  treatment  of 
by  cocaine.  426.  429. 

Collapse  from  ether,  and  treat- 
ment of,  153. 

Cone  and  its  modifications,  cone, 
244.  508  ;  ether,  169,  171. 

Coltou.  Dr.,  safety  in  diseases  of 
nitrous  oxide,  119. 

Conclusions  of  experiments  upon 
the  brain  and  spinal  cord 
with  nitrous  oxide,  83. 

Corning,  Dr.  J.,  early  introduc- 
tion of  the  use  of  cocaine  by 
electricity,  372. 

Coryza,  treatment  by  ether,  196. 


DA  COSTA,  Dr.  J.  C,  blood  alter- 
ations by  ether,  219. 

Dangers,  chloroform,  ether,  132; 
treatment  of.  152. 

David,  Dr.  Th.,  director  of  L'Ecole 
Dentaire  of  Paris,  conclu- 
sions on  extraction  of  teeth 
under  anesthesia,  112. 

Davy,  Sir  Humphrey,  experi- 
ments with  nitrous  oxide,  27. 

Deaths  from  alcohol,  137,  140, 
142,  145,  146 ;  amvlene,  207 ; 
cocaine,  416 ;  ether.  153-293  ; 
chloral  hvdrate.  208:  chloro- 
form. 214^  252,  253.  308 ;  ethyl 
bromide.  232.  235;  nitrous 
oxide.  112.  113.  114,  115; 
ether,  a  death.  309;  ethyl 
bromide,  227  :  after  cessation 
of  anaesthetic  and  return  to 
consciousness.  189. 

Degeneration  of  vessels  from  dis- 
ease,     anaesthetics     to     be 


542 


INDEX. 


avoided  in  such  cases,  127; 
death  from,  115,  116. 

Dental  operations,  accidents  in 
extracting  teeth,  Buxton  on, 
109  ;  in  children,  111 ;  chloro- 
form in,  329;  paper  read  by 
Dr.  Hewitt  before  British 
Dental  Association  on,  329 ; 
table  of  deaths  and  general 
condition,  332. 

Denison,  Dr.  Chas.,  on  importance 
of  aseptible  syringe  for  solu- 
tion of  cocaine,  402. 

Delirium,  from  use  of  nitrous 
oxide  in  a  chronic  drinker, 
127  ;  from  chloroform,  533 ; 
ether,  197. 

Diarrhoea,  use  of  camphor  and 
ether  in,  195. 

Dioscorides  on  the  use  of  mandra- 
gora,  25. 

Diphtheria,  treatment  by  ether 
iodol,  197,  472. 

Dogs,  experiments  by  H.  C.  Wood 
on,  127 ;  oxygen  and  nitrous 
oxide  on,  188;  ether  and 
chloroform,  188;  vivisection 
by  Prof.  Schaffer's  bromo- 
form,  205 ;  bromide  of  ethyl, 
229-230 ;  chloroform,  by  Dr. 
Strassman,  288 ;  cocaine,  389  ; 
experiments  by  Drs.  Eeichert 
and  Turnbull,  390-392. 

Dysmenorrhcea,  treatment  of  by 
ether,  camphor,  etc.,  195. 

E.  C.  MIXTUEE,  351. 

Emmet,  the  late  Dr.,  danger  of 
nephritis  from  ether,  213. 

Ephedrine  chlorohydrate,  459. 

Epiglottis,  Howard's  new  way  of 
raising,  263 ;  new  way  of  ex- 
amining, 264. 

Epilepsy,  treatment  by  ether  and 
camphor,  195  ;  nitrous  oxide 
in,  116-122. 

Ether,  ethyl,  action  on  circula- 
tion, 156-157 ;  action  on 
brain,  head  and  circulation, 
155 ;  after-effects  of,  318,  533 ; 
apparatus  for  administra- 
tion per  rectum,  191-192;  as 
angesthetic,  149 ;  chemical 
composition,    148 ;    chemical 


properties,  149;  chemical  re- 
action, 148;  chief  dangers 
from  administration  by  rec- 
tum, 191-192 ;  cone,  use  and 
modificatious  of,  169-171 ; 
danger  from  the  cold  and 
watery  vapor,  356;  dangerous 
symptoms  and  treatment  of, 
152,  494 ;  ethyl  oxide,  ether  of 
commerce,  148;  experiments 
on  deaths  from  ether  fortior, 
155;  how  manufactured,  148  ; 
inflammability  of,  152;  in- 
halation of,  149-150 ;  inhalers 
for,  157-186;  the  Allis,  157- 
166;  Cheatham's,  173;  Clover's 
small,  166-167  ;  Codman  and 
Shurtleflf's,  176 ;  Hearn's,  171 ; 
Lente's,  170 ;  Ormsby's,  171 ; 
Parkinson's,  174;  Souchon's, 
178 ;  inhalation  of  to  pro- 
duce ansesthesia,  149-150  ; 
internal  administration  of, 
193-195 ;  intoxication  by, 
197-199 ;  is  it  possible  to  have 
death  produced  by  an  anaes- 
thetic some  time  after  cessa- 
tion of  administration  by 
rectum  ?  191  ;  mode  of  deter- 
mining its  purity  for  inhala- 
tion, 149;  or  chloroform,  which 
(?),  211 ;  physiological  action 
of,  153;  precautions  before 
and  after  use  as  an  anaes- 
thetic, 151, 490 ;  specific  grav- 
ity, 489 ;  sphygmographic 
tracings  from,  155 ;  tissue 
changes  found  in  cases  of 
secondary  death  after,  186. 

Ethyl  chloride,  441 ;  and  pental, 
444. 

Ethylene  bromide,  204. 

Ethylene  chlorhydrin,  204. 

Eucalyptus,  454. 

Eucaine,  hydrochlorate,  434 ; 
chemical  composition,  39-40 ; 
general  action  of,  435 ;  and 
cocaine,  437 ;  local  action  on 
the  eye  of,  436-437 ;  in  dent- 
istry "^  and  minor  surgery, 
438-441. 

Evans,  Dr.,  of  Paris,  reintroduc- 
tion  of  nitrous  oxide,  29. 

Exalgin,  485. 


INDEX. 


543 


Experimeuts,  abstract  of  the 
deadly  after-eflects  of  chlo- 
roform, by  Drs.  C.  Thiem  aud 
P.  Fischer,  of  Berlin,  318- 
320;  bromide  of  ethyl  on 
auimals,  229;  bromoform,  by 
Dr.  Krei^er,  205  ;  by  the  late 
Dr.  Washington  Atlee  with 
bichloride  of  methylene, 
203;  by  Dr.  H.  Northrop 
with  oxygen  and  chloroform, 
340:  by"  Dr.  Buxton,  on  the 
physiological  action  of  ni- 
trous oxide.  SO-Sl:  carbonic 
acid  and  oxygen.  Dr.  Wood, 
106  ;  conclusions  by  Dr.  Bux- 
ton on  the  brain  and  spinal 
cord,  S3:  on  arrested  respi- 
ration, by  Drs.  Martin  and 
Hare,  264  ;  first,  second  and 
third  series,  by  McQuillen, 
73 :  on  blood  alterations  by 
ether,  by  JohnC.DaCosta,  219; 
on  the  kidney,  S9 ;  of  Paul 
Bert,  on  compressed  oxygen, 
96  ;  on  the  physiological  ac- 
tion of  ether,  by  Drs.  Eeich- 
ert,  Thomas  and  Turnbull,  on 
use  and  abuse  of  atropine  and 
morphia.  153;  on  the  reflexes 
under  nitrous  oxide  gas,  84  ; 
on  the  action  of  nitrous  ox- 
ide, and  of  the  mixture  of  ni- 
trous oxide  and  oxygen,  by 
Dr.  Wood,  127;  on  the  phy- 
siological action  of  alcohol, 
by  David  Cerna,  M.D..  of 
Texas,  140 ;  on  tissue  changes 
found  in  cases  of  secondary 
death  after  ether,  bv  Drs. 
H.  C.  Wood  and  William  S. 
Carter,  186 ;  on  the  value  of 
oxygen  gas  in  prolonged 
operations  where  ether  has 
been  used,  209-210;  on  the 
physiological  action  of  bro- 
mide of  ethyl,  by  Schneider, 
Aboneje.  Thornton  and  Max- 
well, 229  :  on  local  anaesthe- 
tics, by  Dr.  Leibreich,  371; 
on  osmosis  in  treatment  of 
living  dentine,  by  Henrv  W. 
C4illett,  M.D.,  372;  on  "bro- 
mide of  ethyl,  by  Dr.  Koel- 


licker,  231  ;  proportions  of 
anaesthetic  vapor  and  air  at 
each  compression  of  the  bulb 
of  Souchou's  auxiliary  injec- 
tor, 183 ;  to  determine  the 
time  required  for  evaporation 
on  a  given  surface  of  paper, 
by  the  author  and  Dr.  C.  S. 
Turnbull,  35.5-356;  with  a 
mixture  of  ether  and  bro- 
mide of  ethyl  and  chloro- 
form, by  Drs.  Reichert, 
Thomas  and  Turnbull,  357; 
with  Allis's  inhaler  with 
ether,  bv  Dr.  G.  H.  Coburn, 
164. 

FISCHER,  Dr.  P.,  experiments 
with  Dr.  C.  Thiem  on  the 
after-efi"ects  of  chloroform, 
318. 

Flatulent  dyspepsia,  carbolic  acid 
in,  476. 

Formad,  Dr.,  influence  of  alcohol 
on  the  kidnevs  and  liver, 
141-146. 

Formic  ether,  201. 

GAEDEKE,  discovery  of  ery- 
throxyline,  38. 

Galvanism  in  chloroform  nar- 
cosis, 495 ;  in  ether,  1.52  ;  in 
treatment  of  living  dentine, 
375  :  by  Herapath's  method, 
152. 

Gaskell  and  Shore,  Drs.,  new 
views  of  anaesthetics,  280, 
281 :  answer  by  Hare,  507. 

Garretson,  the  late  Dr.,  use  of 
phenic  acid  and  cocaine  in 
solution,  393. 

Gastritis  produced  by  "  Rough 
on  Rats,"'  treatment  by  co- 
caine, 422. 

Geographical  distribution  of  fa- 
talities from  chloroform, 
252. 

Gillett,  Henry  W.,  M.D.,  electrical 
osmosis  for  treatment  of  liv- 
ing dentine,  370-376. 

Glottis,  spasm  of,  from  cocaine, 
chloroform,  262-264;  ether, 
150-1.52  ;  nitrous  oxide,  108- 
110;    treatment  of,  262-264. 


544 


INDEX. 


/ 


Goodell,  Dr.  Wm.,  experience 
with  ether.  165. 

Goodwillie,  Dr.  H.,  surgical  oper- 
ations under  nitrous  oxide, 
94-95. 

Gonorrhceal  ophthalmia,  treat- 
ment by  cocaine,  431. 

Gout,  treatment  by  ether,  194. 

Gray,  Dr.,  use  of  eucaine  as  an 
ansesthetic,  441, 

Guaiacol,  with  cocaine,  486. 

Guthrie,  Mr.  Samuel,  discovery 
of  chloroform  by,  35. 

HABIT,  chloroform,  532. 

Halliburton,  Prof.,  University 
College,  London,  examina- 
tion of  the  blood  in  nitrous 
oxide  anaesthesia  by,  SO. 

Hammond,  Dr.,  experiments 
with  cocaine  by,  394-395. 

Hamilton,  Dr.  A.  McLane,  use  of 
nitrous  oxide  in  insomnia, 
epilepsy,  neuralgia  by,  117 ; 
functional  heart  disorders, 
118. 

Hare,  Dr.  Hobart  A.,  treatment 
of  arrested  respiration  by, 
264;  conclusions  with  Dr. 
Martin,  273;  experiments 
with  H.  C.  Wood,  M.D.,  500  ; 
reply  to  the  Hyderabad  Com- 
missions, 500. 

Harley,  Dr.,  introduction  of  alco- 
hol in  mixed  ansesthetics, 
353. 

Hay  fever,  the  late  Sir  Andrew 
Clark's  treatment  of,  427 ; 
treatment  by  cocaine,  by  J. 
M.  DaCosta,  429. 

Heart,  action  of  ether  upon, 
155-157 ;  causes  of  death 
from  ether,  treatment  with 
strychnine,  153 ;  which  an- 
sesthetic  to  employ  for  dis- 
eases of,  510. 

Heat  produced  by  cocaine,  392. 

Hegar  and  Kaltenbach,  experi- 
ments by,  319  ;  unchanged 
chloroform  found  in  urine 
by,  319. 

Helleborine,  461. 

Haemorrhage  in  use  of  bromide 
of  ethyl,  no  increase  of,  229. 


Hewitt,  Dr.  F..  apparatus  for  ad- 
ministering nitrous  oxide 
and  oxygen,  portable  and 
simplified,  96-97;  Dr.  J.  D. 
Thomas,  use  of  this  method 
in  extracting  teeth.  101;  his 
objection  to  the  face-piece  of, 
102;   conclusions  of,  102-103. 

Hillischer,  Prof.,  of  Vienna,  use 
of  mixture  of  oxygen  with 
nitrous  oxide  as  an  anaes- 
thetic, 99. 

Hirsch,  Dr.  A.  B.,  value  of  oxy- 
gen gas  after  prolonged  oper- 
ations with  ether,  209-210. 

Hoarseness,  426-428. 

Homatropine.  458. 

Horsley,  Prof.,  on  patellar  tendon 
phenomena  under  profound 
anaesthesia,  84. 

Hospital  records  of  cases  of 
anaesthesia,  317-318. 

House  surgeons,  the  need  of  pro- 
per instruction,  507,  516,  517, 

Howard,  Dr.,  method  of  raising 
the  epiglottis,  263. 

Hunger,  insatiable,  relieved  by 
cocaine,  423. 

Hyderabad  Commission,  answers 
to  cause  of  death,  299;  cause 
of  death  stated  by,  298 ; 
history  of,  293;  table  of 
deaths  from  chloroform  and 
ether  from  the  first,  306  (notes 
on  306-309) ;  tests  of  the  suit- 
ability and  safety  of  it,  294 ; 
Dr.  Brunton's  giving  away 
the  whole  case,  281 . 

Hydrastis  canadensis  and  Hydras- 
tine,  457. 

Hydrate,  chloral,  208. 

Hydriodic  ether,  201. 

Hydrobromate  of  homatropine, 
459. 

Hydrobromic  ether  (see  Bromide 
of  Ethyl). 

Hydrocele,  deaths  from  injection 
of  cocaine,  420-421. 

Hypnal,  485. 

Hypnotics,  479. 

Hypnotism,  534-536. 


INFILTEATION 
399-411. 


anaesthesia, 


INDEX. 


545 


Inhalation  of  chloroform  hy  the 
nose,  objections  to,  by  Dr.  M. 
A.  Gueriu,  of  Paris,  508; 
Souchou,  use  of  inhalation 
by  the  nose.  178-1S6. 

Inhalers,  the  Allis.  shut  and 
open,  157-165  ;  Buxton's,  Dr., 
modification  of  Clover's,  for 
nitrous  oxide  and  ether,  67- 
68;  of  Junker's,  246,  368; 
Codmau  and  Shurtleff's,  ni- 
trous oxide,  etc.,  177;  cone, 
modifications  of  169,  171 ; 
Esmarch's,  chloroform,  mod- 
ified by  Charriere,  Paris,  246  ; 
French  navy,  employed  in, 
245 ;  Hewitt's,  for  nitrous 
oxygen  and  oxygen,  97;  in- 
jector of  Souchou's  for  use 
in  operations  on  face  and 
mouth,  178;  Lawrie's,  modi- 
fied by  Krohne,  507,  508,  and 
Lewis  and  Long,  nitrous  ox- 
ide, 69 ;  Seseman.  506 ;  Lente 
(ether),  170 ;  Ormsby,  im- 
proved, 171 ;  Skinner's,  for 
chloroform,  245 ;  Thomas 
(nitrous  oxide),  46;  S.  S. 
White  Co.,  47-5.3. 

Insanity  from  prolonged  use  of 
anaesthetics,  127. 

Insomnia,  use  of  nitrous  oxide 
in,  117 ;  use  of  ethylene  bro- 
mide in,  204. 

Instability  of  cocaine,  388;  use 
of  quinia  in  intermittent 
fever,  478. 

Intoxication  from  alcohol,  139 ; 
ether,  197;  in  Ireland,  198; 
in  Eussia,  198. 

Iodide  of  ethyl.  474. 

Iodide  of  methyl,  206,  456. 

lodol,  468. 

Iodoform,  462-468. 

Irregular  action  of  anEesthetics 
in  bromide  of  ethyl,  233; 
chloroform.  2.58. 

Irritation  of  skin,  treatment  of, 
425. 

JACKSON,  Dr.,  part  in  the  dis- 
covery of  anaesthetics  (ether), 
32. 

Jolyet  and  Blanch's  experiments, 


and  references  to  them,  77, 
100,  128. 
Junker's  inhaler,  246,  368. 

KAST,  doubts  whether  or  not 
chloroform  is  changed  in  the 
urine,  319. 

Kiduevs,  action  of  alcohol  on, 
142,  143,  187,  224;  disease  of, 
which  ansesthetic  to  employ, 
whicii  to  avoid,  511;  action 
of  chloroform  on,  224-226; 
action  of  ether  on,  186,  187; 
experiments  with  nitrous  ox- 
ide, 89;  the  influence  of 
aneesthetics  on,  bv  the  late 
Dr.  Emmet  and  Prof.  W.  F. 
Xorris,  225. 

Kirk,  Dr.,  on  Dr.  Hewitt's  me- 
thod of  using  nitrous  oxide 
and  oxygen  as  an  ausesthetic, 
its  safetv.  etc.,  102. 

Klikovich,  Dr.  Si,  of  St.  Peters- 
burg, experiments  with  a 
mixture  of  nitrous  oxide  and 
oxygen,  96. 

Koellicker  recommends  bromide 
of  ethyl,  231. 

Koller,  Dr.  Karl,  of  Vienna,  dis- 
coverer of  anaesthetic  power 
of  cocaine  on  the  eve,  etc., 
38. 

Krohne's  and  Seseman's  respira- 
tion indicator  attachment, 
505,  508. 

LABOE,  use  of  nitrous  oxide  and 
oxygen  in.  by  Klikovich  and 
Zweifel,  123. 

Laryngeal  tuberculosis,  treat- 
ment of,  427 

Larynx,  spasm  of,  chloroform, 
ether  and  cocaine  in  disease 
of,  384;  nitrous  oxide,  108, 
110. 

Laughing  gas  (see  Nitrous  Ox- 
ide), 27. 

Lawrie,  Dr.,  arrangement  of  Hy- 
derabad Commissions,  293 ; 
strictures  and  conclusions, 
answer  to.  299  ;  unfair  state- 
ments, 325,  328. 

Lavage  or  gavage,  painful  treat- 
ment by  cocaine,  423. 


546 


INDEX. 


/ 


Levis,  Dr.,  cases  of  death  from 
impure  bromide  of  ethyl,  235. 

Lewis,  Dr.  Bransford,  of  St. 
Louis,  use  of  Schleich's  me- 
thod, 410. 

Liebreich,  Dr.  M.  Oscar,  sub- 
stances which  produce  local 
ansesthesia,  371,  .372. 

Liniments  for  relief  of  neuralgia, 
etc.,  554. 

Link,  Dr.  John  E.,  on  the  use  of 
whiskey  as  an  anaesthetic, 
137,  138. 

Local  anaesthesia  and  anes- 
thetics, 371 ;  absolute  alco- 
hol, acetate  of  lead,  antipy- 
rine,  carbolic  and  carbonic 
acid,  bromide  of  ethyl,  car- 
bon bisulphide,  chloroform, 
cold,  ice  and  snow,  ether,  hy- 
drochlorate  of  ammonia,  hy- 
droquinine,  rhigolene,  resor- 
cin,  sulphate  and  bromide  of 
ammonia,  the  iron  salts,  how 
they  act,  371. 

Local  ansesthetics  and  analgesics, 
antipyrine,  antifebrin,  apo- 
morphine,  bromide  of  ethyl, 
bromide  of  potassium,  bru- 
cine,  electricity,  371,  372. 

Long,  Dr.,  experiments  with 
ether,  32. 

Longet,  on  narcosis  from  ether, 
155. 

Loyssel,  Dr.,  experiments  with 
oxygen  as  an  antidote  to 
chloroform,  339. 

McDonald,  Dr.  L.,  nitrous  ox- 
ide in  general  surgery,  94. 

MacEwen,  of  Glasgow,  the  pupil 
in  suspended  function  of 
brain  from  want  of  oxygen- 
ated blood,  259. 

Mandragora  wine,  26. 

Martin,  M.  Claude,  of  Lyons,  ex- 
periments with  a  mixture  of 
nitrous  oxide  and  oxygen 
administered  to  dogs,  101. 

Martin,  Dr.  Edward,  on  treat- 
ment of  arrested  respiration, 
264. 

Mays,  Dr.,  of  this  city,  successful 
use  of  brucine  by,  459,  460, 


Maximum  dose  of  cocaine,  397. 

Mattison,  Dr.  J.  B.,  of  Brooklyn, 
deaths  from  cocaine  toxsemia, 
417. 

McQuillen,  the  late  Dr.,  experi- 
ments on  the  action  of  chlo- 
roform on  the  blood,  71-74. 

McWilliams,  experiments  and  ob- 
servations to  Dr.  Lawrie,  298. 

Medico-legal  relations  of  anaes- 
thetics in  France,  112 ;  in 
Ireland  and  Eussia,  198. 

Mental  disturbance  and  insanity, 
127 ;  from  chloroform,  533. 

Menthol,  462. 

Mesmerism  (see  Hypnotism). 

Methyl-violet,  482. 

Methyl,  456. 

Methyl,  chloride  of,  local  anaes- 
thetic, danger  from  too  free 
use,  457 ;  iodide  of,  206. 

Methylic  ether,  201. 

Methylene,  bichloride  of,  202; 
Dr.  Richardson's  mixture  of, 
202,  203  ;  the  late  Sir  Spencer 
Wells's  use  of,  202,  203. 

Miller,  Dr.  John  S.,  form  of  ap- 
paratus for  use  of  ether  by 
the  rectum,  193. 

Miller,  Jacob  F.,  Esq.,  advocated 
care  in  the  use  of  anes- 
thetics, 518. 

Miles,  Dr.  A.  B.,  ether  or  chlo- 
roform— which  ?  211. 

Mixed  anaesthetics,  232,  233,  351- 
356  ;  report  on,  by  chloroform 
committee,  Med.  Chir.  Soc. 
of  London,  first  death  bj-  M. 
Perrin,  .351 ;  second,  by  Dr. 
E.  Crockett,  351. 

Montgomery,  Dr.  E.  E.,  bromide 
of  ethyl  as  an  anaesthetic  in 
labor,  236-238. 

Morphine  and  atropine  before 
chloroform,  experiments  of 
the  Paris  Society  of  Surgery, 
303,  304 ;  and  ether  and  chlo- 
roform, 1.53. 

Morgan,  the  late  Dr.,  of  Dublin, 
substitution  of  ether  for 
whiskey,  198. 

Morton,  results  obtained  with 
ether  in  Mass.  Gen.  Hospital 
by,  31,  32. 


INDEX. 


547 


Hosier,  treatment  of  asthma  by 
cocaiue,  429. 

Mosso,  of  Turin,  experiments 
showing  an  increase  of 
bodily  temperature  by  the 
use  of  cocaine,  390,  391. 

Mott,  the  late  Valentine,  objec- 
tions to  the  use  of  brandy  in 
surgical  operations,  139. 

Mowat.  Sphygmographic  tracings 
from  pulse  under  nitrous 
oxide,  90,  91. 

XAXCEEDE,  Dr.,  directs  tongue 
to  be  drawn  out  to  lift  up  the 
epiglottis.  1.52. 

Xaphthaline,  4S5. 

Nelaton,  treatment  of  dangerous 
symptoms  after  using  ether 
as  an  anaesthetic  by,  152. 

Nephritis,  danger  of.  by  action 
of  blood  saturated  with  ether, 
213. 

Nervous  symptoms,  treatment  of 
by  ether  and  camphor.  195. 

Neuralgia,  which  aneesthetic  to 
employ.  510. 

Niemanns.  Dr.  Albert,  33. 

Nipples,  treatment  of  cracked,  by 
cocaine,  425. 

Nitrite  of  amyl,  the  employment 
of.  291 :  non-success  with. 
291. 

Nitrogen  gas.  action  when  in- 
haled solely  without  oxygen, 
70 ;  after-effects  of,  107 ; 
deaths  under,  112-115 ;  ex- 
periments with  nitrous  oxide 
gas  and  nitrogen,  105. 

Nitrous  oxide,  administration  to 
children,  111;  after-effects  of 
accidents  in  extracting  teeth 
under,  112 ;  after-effects  of, 
107;  as  an  anesthetic  in 
labor,  ]23;  and  oxygen,  95; 
blood  alterations,  conclu- 
sions, 92,  93 ;  chemical  com- 
position and  mode  of  prepa- 
ration, 41-43 ;  conclusions 
of  experiments  on  the  brain 
and  spinal  cord,  53,  S4 ;  dan- 
ger of,  bv  Dr.  J.  D.  Thomas, 
107;  deaths  under,  112-116; 
experiments   with,    73;    ex- 


periments with  on  kidneys, 
89 ;  experiments  with  the 
spectroscope,  74,  75;  experi- 
ments on  respiratory 
rhythm,  69 ;  on  men,  pigeons, 
rabbits,  by  Dr.  C.  S.  Turn- 
bull  and  associates,  75  ;  gaso- 
meter, 53  ;  heart  disease,  120; 
Hewitt's  apparatus  for  ad- 
ministration with  oxygen, 
97-99;  in  general  surgery, 
94,  95  ;  in  chorea,  epilepsy, 
hysteria.  121 ;  inhaler.  46-51 ; 
its  safety  as  a  therapeutic 
agent  in  diseases  of  the 
lungs,  119 ;  nervous  diar- 
rhoea, sluggish  circulation 
and  nervous  prostration, 
126;  on  insanity  or  mental 
disturbance  following  an 
operation  with  prolonged 
use  of,  127'  original  experi- 
ments on  the  action  of.  and 
oxvgeu  with,  by  H.  C.  Wood, 
M.D.,  127-134:  physical 
properties  and  physiological 
action,  69-71 ;  proper  method 
of  administration.  65;  re- 
flexes under,  S4-55 ;  thera- 
peutic application  of,  116- 
116 ;  wall  bracket  for  office 
and  surgeon's  cases,  for  use 
of,  63-65. 
Northrop,  Dr.  H.  L.,  reasons  for 
the  administration  of  oxy- 
gen with  chloroform,  340, 
341 ;  report  on  experiments, 
342 :  use  of  apparatus,  345^ 
348.' 

0D0NT0L0C4ICAL  Society  of 
Great  Britain,  committee 
found  averages  in  administra- 
tions of  nitrous  oxide,  91,  92. 

Officiers  de  Sante  of  France,  den- 
tists who  hold  no  diploma 
have  no  right  to  extract 
teeth  except  under  supervi- 
sion of  doctor.  111. 

Olefiant  gas  'see  Ethylene;. 

Ophthalmic  surgery,  cocaine  as  a 
local  angesthetic,  its  import- 
ance in  operations  on  the 
eye,  38, 


/ 


548 


INDEX. 


Opium  as  a  narcotic,  aud  use  as 
an  ansesthetic,  26. 

Ovariotomy,  use  of  nitrous  oxide 
in,  95  ;  in  general  sui-gery,  94. 

Oxide,  ethyl,  as  an  aufesthetic, 
148. 

Oxygen  gas.  apparatus  for  the 
administration  of,  with  chlo- 
roform, 345,  346 ;  average 
period  of  inhalation  of  the 
combined  gases,  100 ;  in  pro- 
longed operations,  in  which 
ether  has  been  administered, 
209,  210  ;  inhaling  apparatus 
for,  349;  nitrous  oxide  aud, 
with  experiments  by  Dr.  H. 
C.  Wood,  127-132, 134  ;  thera- 
peutic use,  with  nitrous  ox- 
ide, 124-126;  Drs.  Wood  and 
Cerna  on  the  combined  gases, 
104;  when  the  gas  is  to  be 
preferred,  conclusions  by  Dr. 
Hewitt,  102. 

PARALYSIS  from  nitrous  oxide, 
127;  treated  by  nitrous  ox- 
ide, 122. 

Pental,  original  experiments  on 
dogs,  by  Dr.  H.  C.  Wood,  449. 

Pereira's  use  of  ether  to  relieve 
the  effects  caused  by  chlo- 
rine gas,  31 ;  before  its  intro- 
duction as  an  ansesthetic,  31. 

Perrin,  M.,  first  death  from 
mixed  anaesthetics,  351. 

Pharynx  and  naso-pharynx 
treated  by  compound  spray 
of  cocaine,  415. 

Pharyngitis,  granular  use  of  co- 
caine in,  384,  428. 

Phenic  acid  in  solution  for  ex- 
traction of  teeth.  398  ;  use  of, 
by  the  late  Dr.  Garretson,  398. 

Phenol  and  camphor,  450. 

Phenol,  mentho,  451 ;  properties 
and  uses,  451. 

Phthisis,  which  anaesthetic  to 
use,  510. 

Physicians,  their  legal  responsi- 
bility in  the  administering 
of  anaesthetics,  516. 

Pneumonia  following  careless 
use  of  ether  treated  by  ni- 
trous oxide,  119. 


Poisoning  by  cocaine,  use  of 
ether  aud  chloroform  in,  398. 

Post-partum  haemorrhage,  ether, 
195. 

Priestly  and  Scheele,  study  and 
application  of  "different 
kinds  of  airs  and  gases,"  and 
their  discovery  of  oxygen,  27. 

Precautious  to  be  taken  in  ad- 
ministration of  chloroform, 
ether  aud  nitrous  oxide,  494. 

Prevention  of  death  from  ether, 
210 ;  chloroform,  339. 

Prop  of  wood  or  rubber  to  keep 
the  mouth  open,  66. 

Proper  use  of  morphia  and 
chloroform,  303. 

Pruritus  vulva,  treatment  by 
cocaine  of,  425. 

Pulse,  during  chloroform  anaes- 
thesia, 296. 

Pyoktanin,  482. 

QUININE,  478. 

Quimby,  Dr.  J.  M.,  experiments 
on  the  use  of  chloroform 
while  the  patient  is  asleep, 
527-529. 

EECOEDS,  hospital,  examination 
of  urine,  317:  before  opera- 
tion, 321 ;  of  autopsy,  318. 

Eectum,  use  of  ether  by,  191 ; 
chief  dangers  from,  191-192  ; 
chief  dangers  from  apparatus, 
192-193. 

Eeicherts.  Prof.,  studies  with  co- 
caine on  animals,  389-392; 
chloroform,  500. 

Eegnier,  M.,  use  of  hypodermic 
of  morphia  and  atropine  be- 
fore inhalation  of  chloro- 
form, 303. 

Eesearches  of  Bowditch  and 
Minot,  157. 

Eesorcin  and  cocaine  in  whoop- 
ing-cough, 428. 

Eespiration,  artificial,  Sylvester's 
method,  276 ;  arrested  respi- 
ration in  anaesthesia,  280; 
the  feet  should  be  well  drawn 
up,  276  ;  irregularity  in  use 
of  chloroform,  290-291;  im- 
portance of  prolonged,  303. 


IXDEX. 


549 


Eesuscitatiou.  electricity  iu,  496; 
Kouik's.  497;  Kelly's,  497; 
by  lingual  traction,  2S2  ;  by 
rhythmic  traction  of  the 
tougue  iu  accidents  and  from 
chloroformizatiou.  264. 

Eichardsou,  Dr.  B.  W.,  of  Lon- 
don, experiments  with  me- 
thylic  ether,  bichloride  of 
methvl.  201 ;  with  iodide  of 
methyl.  206.' 

Eichardsou,  Dr.  M.,  report  of  ele- 
ven deaths  from  cocaine,  420. 

Eiddle,  Daniel  S.,  Esq.,  of  Xew 
York,  opinion  in  regard  to 
the  enactment  of  further  law 
on  responsibility  of  physi- 
cians, .517. 

SAXSOM,  Dr..  testimony  as  to 
the  stimulating  effects  of 
alcohol  in  counteracting  the 
depressing  influence  of  chlo- 
roform, .35.3. 

Schiff,  Prof.,  of  Geneva,  on  vivi- 
sections, the  safety  of  ether, 
deaths  from  chloroform.  200. 

Schleich's  infiltration  method  of 
local  anfesthesia  by  cocaine. 
399. 

Sciatica,  treatment  of,  511. 

Scotch  method  of  administering 
chloroform,  248. 

Sepsis  after  use  of  cocaine,  danger 
of,  405 :  Schleich's  method, 
405-406. 

Sexual  excitement,  525 ;  ether 
and  camphor  in,  195. 

Shepard,  Col.  J.,  death  from 
ether,  310-311. 

Shock,  1.53,  353. 

Sims,  Dr.  Marion,  use  of  nitrous 
oxide  in  difficult  and  pro- 
longed operations,  95. 

Skin  disease,  the  use  of  cocaine 
in  its  treatment,  424. 

Sneezing,  paroxysmal,  treatment 
of,  by  cocaine,  428. 

Snow's  table  showing  the  amount 
of  chloroform  vapor  which 
can  be  held  in  solution  by 
air,  255-256. 

Souchon's  improvedansesthetizer, 
369. 


Spasm  of  stomach,  intestines 
or  heart,  use  of  ether  in, 
194. 

Squibb,  Dr.  Edward,  on  the  in- 
flammability of  ether.  152. 

Stenosis  or  vulvular  disease, 
which  ansesthetic  to  employ, 
510. 

Stomach  affections  treated  by 
cocaine,  422. 

Students,  facts  for,  488,  517. 

Struggling,  violent,  the  dangers 
of.  under  chloroform,  506. 

Strychnine  in  chronic  alcohol- 
ism, 147  ;  in  heart  failure  in 
chloroform,  153. 

Sulphonal,  480. 

Supplement  of  facts  in  anaesthe- 
sia for  the  student  to  commit 
to  memory,  488. 

Surgery,  cerebral,  what  anes- 
thetic to  give  and  which  not 
to  give,  509. 

Surgeons,  their  responsibility  for 
the  life  of  the  patient,  516. 

Syncope,  primary,  from  chloro- 
form, Dr.  Eobert  Kirk,  of 
Edinburgh,  3.32,  49S. 

TABLE  of  deaths  from  chloro- 
form and  ether  since  the 
Hyderabad  Commission,  by 
the  writer,  307. 

Tables  of  deaths  from  various 
aneesthetics,  by  George  M. 
Gould.  314. 

Tables  of  Committee  of  the 
Odontological  Society  of 
Great  Britain  on  average 
of  administration  of  nitrous 
oxide,  92. 

Tape-worm,  use  of  ether,  etc..  in, 
194. 

Tetanus  treated  by  morphia  and 
cocaine.  424. 

Tissue  changes  found  in  cases  of 
secondary  death  after  ether, 
156;  from  chloroform,  318. 

Therapeutics  of  cocaine,  422. 

Therapeutic  application  of  ni- 
trous oxide  in  nervous 
aphonia,  neuralgia,  asthma, 
116  :  insomnia,  by  A.  McLane 
Hamilton,  117. 


/ 


550 


INDEX. 


Thompson,    Elihu,    experiments 

with  nitrogen,  128. 
Thornton,  Dr.  E.  Q.,  experiments 

with  Dr.  Hare,  502. 
Thymol,  479. 
Trional  and  tetronal,  485. 
Tropacocaine,  486. 
Turnbull,  Dr.  C.  S.,  experiments 

of,  75-79,  357. 

UEETHANE,  484. 

VALUE  of  anaesthetics  in  dis- 
ease, 509. 

Vapor  of  anaesthetics,  boiling 
points,  353. 

Vernuil,  experiments  with  bro- 
mide of  ethyl,  230. 

Viau,  Prof.,  use  of  phenic  acid, 
and  cocaine,  398. 

Vomiting,  uncontrollable,  treated 
by  cocaine,  423 ;  how  to  pre- 
vent it,  151,  489,  496. 

WATEE  produced  from  the  evap- 
oration of  ether,  danger  from, 
356;  as  a  local  anaesthetic, 402. 

Wells,  Horace,  discoverer  of  an- 
aesthesia with  nitrous  oxide, 
28 ;  monument  to,  29. 

Whether  chloroform  may  be  ad- 
ministered for  improper  pur- 
poses, Dr.  J.  M.  Quimby,  527 ; 
case  at  ISTorthamptou,  Eng- 
land, 522;  case  reported  by 
Dr.  K  L.  Folsom,  526. 


Which  anaesthetic  to  avoid, 
whose  to  employ,  509. 

Whooping-cough,  treatment  by 
bromoform,  205 ;  by  cocaine, 
427  ;  by  ether,  197. 

Women  without  attendants,  be- 
ware of  chloroforming  them, 
5.30. 

Wood.  G.  B.,  M.D..  the  influence 
of  anaesthetics  on  the  kid- 
neys, more  especially  ether 
and  chloroform,  224. 

Wood,  Dr,  H.  C,  action  of  ether 
on  the  circulation,  156 ;  ex- 
periments on  nitrous  oxide 
by,  127 ;  abstract  from  a  mon- 
ograph on  experimental  study 
of  nitrous  oxide  with  Dr.  D. 
Cerua,  105  ;  on  carbonic  acid 
and  oxygen,  106;  that  ni- 
trous oxide  should  not  be 
employed  where  there  is  de- 
generation of  vessels,  127. 

Wooden  prop  to  keep  the  mouth 
open  when  employing  nitrous 
oxide  gas,  66. 

Wiirdemann,  Dr.  H.  V.,  first  to 
use  the  Schleich's  infiltration 
method  in  the  United  States, 
399. 

ZWEIFEL  proved  chloroform  to 
be  present  in  the  urine  of 
the  new-born  infant  whose 
mother  had  been  given  chlo- 
roform, 319. 


HD81 
Turnbull 


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1896 


A-.-t  -:  x>i  _  ^  _  T 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  81  T84  1896  C.I 

Artificial  anaesthesia,  a  manual  of  anae 


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